Healthcare Provider Details

I. General information

NPI: 1841249489
Provider Name (Legal Business Name): BRADLEY MARTIN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 10/17/2025
Certification Date: 10/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 HIGHWAY 51 N
BROOKHAVEN MS
39601-2079
US

IV. Provider business mailing address

3688 VETERANS MEMORIAL DR STE 200
HATTIESBURG MS
39401-8246
US

V. Phone/Fax

Practice location:
  • Phone: 601-554-7400
  • Fax:
Mailing address:
  • Phone: 601-554-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA00053
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: