Basic Information
| Provider Information | |||||||||
| NPI: | 1295246049 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARTER | ||||||||
| FirstName: | BRADIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4480H S COBB DR SE # 325 | ||||||||
| Address2: | |||||||||
| City: | SMYRNA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300806958 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 711 CANTON RD NE STE 300 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6787415000 | ||||||||
| FaxNumber: | 6788194280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2017 | ||||||||
| LastUpdateDate: | 03/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 8565 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 003202090B | 05 | GA | MEDICAID |