Healthcare Provider Details

I. General information

NPI: 1033483458
Provider Name (Legal Business Name): BOBBY JOEL TREADWELL JR. PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2012
Last Update Date: 10/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4550 COBB PARKWAY NORTH NW SUITE 309B
ACWORTH GA
30101-4180
US

IV. Provider business mailing address

4550 COBB PARKWAY NORTH NW SUITE 309B
ACWORTH GA
30101-4180
US

V. Phone/Fax

Practice location:
  • Phone: 770-917-6795
  • Fax: 770-529-9077
Mailing address:
  • Phone: 770-917-6795
  • Fax: 770-529-9077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5730
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: