Healthcare Provider Details

I. General information

NPI: 1811322340
Provider Name (Legal Business Name): ANGIE S BRADLEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANGIE STREETMAN

II. Dates (important events)

Enumeration Date: 09/03/2013
Last Update Date: 01/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 STONEBRIDGE PARKWAY SUITE 200
WOODSTOCK GA
30189
US

IV. Provider business mailing address

300 TOWER ROAD SUITE 200
MARIETTA GA
30060-9403
US

V. Phone/Fax

Practice location:
  • Phone: 770-926-9112
  • Fax: 770-926-8240
Mailing address:
  • Phone: 770-427-5717
  • Fax: 770-514-5040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number006885
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: