Provider Demographics
NPI:1811322340
Name:BRADLEY, ANGIE S (PA-C)
Entity type:Individual
Prefix:
First Name:ANGIE
Middle Name:S
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANGIE
Other - Middle Name:
Other - Last Name:STREETMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 TOWER ROAD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-9403
Mailing Address - Country:US
Mailing Address - Phone:770-427-5717
Mailing Address - Fax:770-514-5040
Practice Address - Street 1:1505 STONEBRIDGE PARKWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189
Practice Address - Country:US
Practice Address - Phone:770-926-9112
Practice Address - Fax:770-926-8240
Is Sole Proprietor?:No
Enumeration Date:2013-09-03
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006885363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I971251OtherMEDICARE PTAN