Provider Demographics
NPI:1356432280
Name:BRAGG, PAUL L JR (PA)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:L
Last Name:BRAGG
Suffix:JR
Gender:M
Credentials:PA
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Mailing Address - Street 1:1638 OWEN DR
Mailing Address - Street 2:ATTN:MANAGED CARE PLANNING
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3424
Mailing Address - Country:US
Mailing Address - Phone:910-615-6949
Mailing Address - Fax:910-615-9761
Practice Address - Street 1:1219 WALTER REED RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4437
Practice Address - Country:US
Practice Address - Phone:910-615-3350
Practice Address - Fax:910-321-6253
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2014-09-05
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Provider Licenses
StateLicense IDTaxonomies
NC001005108363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP34437Medicare UPIN
OHBRPA17443Medicare ID - Type Unspecified