Provider Demographics
NPI:1770834764
Name:BRADLEY, TRASSE D (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TRASSE
Middle Name:D
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TRASSE
Other - Middle Name:D
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 746654
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6654
Mailing Address - Country:US
Mailing Address - Phone:904-202-2092
Mailing Address - Fax:904-393-7603
Practice Address - Street 1:1301 PALM AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8432
Practice Address - Country:US
Practice Address - Phone:904-202-7300
Practice Address - Fax:904-202-7433
Is Sole Proprietor?:No
Enumeration Date:2012-10-01
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106836363A00000X, 246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0087529-00Medicaid
GA003138114AMedicaid
FLP01356885Medicare PIN
FL0087529-00Medicaid