Provider Demographics
NPI:1881800654
Name:PAVLAKOVICH, DAVID BRADLEY (PA-C)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:BRADLEY
Last Name:PAVLAKOVICH
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 1:3067 LINDENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-3165
Mailing Address - Country:US
Mailing Address - Phone:803-586-4454
Mailing Address - Fax:
Practice Address - Street 1:3067 LINDENWOOD DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-3165
Practice Address - Country:US
Practice Address - Phone:803-586-4454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1195363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant