Provider Demographics
NPI:1154356889
Name:HOLT, BRADLEY T (PA)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:T
Last Name:HOLT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 18TH ST E STE 400
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3684
Mailing Address - Country:US
Mailing Address - Phone:229-382-9733
Mailing Address - Fax:
Practice Address - Street 1:1641 MADISON AVE
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-3757
Practice Address - Country:US
Practice Address - Phone:229-353-2284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004544363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA777870044CMedicaid
GA777870044BMedicaid
GAQ47553Medicare UPIN
GA777870044CMedicaid