Provider Demographics
NPI:1528033172
Name:LAYMON, BRADLEY L (PA)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:L
Last Name:LAYMON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 601843
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1843
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2452 FAIRLAWN CT
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3884
Practice Address - Country:US
Practice Address - Phone:336-443-9910
Practice Address - Fax:336-443-9909
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103465363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2755454Medicare ID - Type Unspecified
NCS91750Medicare UPIN