Healthcare Provider Details

I. General information

NPI: 1265490098
Provider Name (Legal Business Name): BRADLEY DANIEL PAGE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 02/07/2020
Certification Date: 02/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 PIONEER ST STE C
WAYCROSS GA
31501-6205
US

IV. Provider business mailing address

11608 CENTRAL AVE
HOBOKEN GA
31542-2106
US

V. Phone/Fax

Practice location:
  • Phone: 912-490-7777
  • Fax: 912-490-7778
Mailing address:
  • Phone: 912-288-3417
  • Fax: 912-283-8204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number004775
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4755
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: