Provider Demographics
NPI:1902903008
Name:HOLT, BRADLEY K (PA-C)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:K
Last Name:HOLT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 BRIDGECREEK DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-8908
Mailing Address - Country:US
Mailing Address - Phone:803-234-5423
Mailing Address - Fax:
Practice Address - Street 1:704 BRIDGECREEK DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-8908
Practice Address - Country:US
Practice Address - Phone:803-234-5423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3369363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00403356EMedicaid
GA00403356EMedicaid
GAS92313Medicare UPIN