Provider Demographics
NPI:1578371001
Name:MATHIS, BRADLEY LAMAR
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:LAMAR
Last Name:MATHIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5022 ROWAN RD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37912-3641
Mailing Address - Country:US
Mailing Address - Phone:931-337-2419
Mailing Address - Fax:
Practice Address - Street 1:5022 ROWAN RD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37912-3641
Practice Address - Country:US
Practice Address - Phone:931-337-2419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant