Provider Demographics
NPI:1215971288
Name:SUMRALL, BRADLEY F (PA-C)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:F
Last Name:SUMRALL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 405827
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-5827
Mailing Address - Country:US
Mailing Address - Phone:870-934-5821
Mailing Address - Fax:870-934-5384
Practice Address - Street 1:255 BAPTIST BLVD
Practice Address - Street 2:SUITE 401
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2011
Practice Address - Country:US
Practice Address - Phone:662-244-2288
Practice Address - Fax:662-244-2289
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00066363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04729081Medicaid
MS512I970015Medicare PIN
MS04729081Medicaid