Healthcare Provider Details

I. General information

NPI: 1689358012
Provider Name (Legal Business Name): BRADLEY CAMERON PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 07/18/2026
Certification Date: 07/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 PHILIP BLVD STE A
LAWRENCEVILLE GA
30046-8746
US

IV. Provider business mailing address

301 PHILIP BLVD STE A
LAWRENCEVILLE GA
30046-8746
US

V. Phone/Fax

Practice location:
  • Phone: 770-822-5560
  • Fax: 770-822-4989
Mailing address:
  • Phone: 770-822-5560
  • Fax: 770-822-4989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11792
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: