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General NPI Number Information
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NPI Number | 1063109171
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Entity Type | Individual
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Provider Name | THOMAS BRADFORD GENTLE PA-C
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Gender | Male
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Dates
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Enumeration Date | 04/19/2023
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Last Update Date | 04/19/2023
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Provider Practice Location Address
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Address Line | 115 CHERRY ST NE
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City | MARIETTA
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State | GA
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Zip | 30060-7205
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Country | US
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Telephone | 256-612-8778
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Fax |
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Provider Business Mailing Address
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Address Line | 6404 ASHTON CIR
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City | MONTGOMERY
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State | AL
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Zip | 36117-4902
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Country | US
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Telephone | 256-612-8778
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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