Provider Demographics
NPI:1235945916
Name:BRADFORD, EMALY ELIZABETH (PA-C)
Entity type:Individual
Prefix:
First Name:EMALY
Middle Name:ELIZABETH
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 RESURGENCE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-7211
Mailing Address - Country:US
Mailing Address - Phone:706-204-1694
Mailing Address - Fax:
Practice Address - Street 1:1180 RESURGENCE DR STE 100
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-7211
Practice Address - Country:US
Practice Address - Phone:706-204-1694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-06
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12758363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant