Basic Information
| Provider Information | |||||||||
| NPI: | 1912238460 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | HARPER | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 RT STANLEY SR PL | ||||||||
| Address2: | |||||||||
| City: | LYONS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304365623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125269355 | ||||||||
| FaxNumber: | 9125268622 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 RT STANLEY SR PL | ||||||||
| Address2: | |||||||||
| City: | LYONS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304365623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125269355 | ||||||||
| FaxNumber: | 9125268622 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2010 | ||||||||
| LastUpdateDate: | 03/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 5004636 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | RN218687 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | RN218687 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 003116137A | 05 | GA | MEDICAID | RN218687 | 01 | GA | STATE LICENSE | OTHER |