Healthcare Provider Details

I. General information

NPI: 1407036585
Provider Name (Legal Business Name): BRADLEY EARNEST CARR NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2007
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1348 WALTON WAY STE 5700
AUGUSTA GA
30901-5110
US

IV. Provider business mailing address

PO BOX 1705
AUGUSTA GA
30903-1705
US

V. Phone/Fax

Practice location:
  • Phone: 706-774-7022
  • Fax: 706-774-7023
Mailing address:
  • Phone: 706-774-7263
  • Fax: 706-774-7230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN238860
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: