Provider Demographics
NPI:1568469518
Name:BADGER, BRIAN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:BADGER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 MCMILLAN RD
Mailing Address - Street 2:
Mailing Address - City:OCHLOCKNEE
Mailing Address - State:GA
Mailing Address - Zip Code:31773-1427
Mailing Address - Country:US
Mailing Address - Phone:229-227-9957
Mailing Address - Fax:
Practice Address - Street 1:91 MCMILLAN RD
Practice Address - Street 2:
Practice Address - City:OCHLOCKNEE
Practice Address - State:GA
Practice Address - Zip Code:31773-1427
Practice Address - Country:US
Practice Address - Phone:229-227-9957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3752363AM0700X
GA3435363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003435OtherSTSTE LICENSE #
FL606478700OtherDEPT OF LABOR
FL96317OtherHEALTH PARTNERS
FLPA3752OtherLICENSE #
GA100000360CMedicaid
GA97WCJTFMedicare PIN
FL606478700OtherDEPT OF LABOR
FLPA3752OtherLICENSE #
GA100000360CMedicaid