Healthcare Provider Details

I. General information

NPI: 1447724430
Provider Name (Legal Business Name): COURTNEY PAIGE BRADFORD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2019
Last Update Date: 01/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2936 N ELM ST STE 102
LUMBERTON NC
28358-2981
US

IV. Provider business mailing address

2600 N ELM ST
LUMBERTON NC
28358-3011
US

V. Phone/Fax

Practice location:
  • Phone: 910-671-6619
  • Fax: 910-608-0487
Mailing address:
  • Phone: 910-671-5367
  • Fax: 910-738-3764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number244357
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: