Provider Demographics
NPI:1760683320
Name:HARTMAN, KEVIN BRADLEY (PA-C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:BRADLEY
Last Name:HARTMAN
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 1:1035 SOUTHCREST DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-6118
Mailing Address - Country:US
Mailing Address - Phone:770-389-9005
Mailing Address - Fax:
Practice Address - Street 1:1035 SOUTHCREST DR
Practice Address - Street 2:SUITE 100
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-6118
Practice Address - Country:US
Practice Address - Phone:770-389-9005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA-9104168363A00000X
GA005235363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant