Provider Demographics
NPI:1902981996
Name:RIDGE, BRADLEY GENE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:GENE
Last Name:RIDGE
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 1:3294 NORTH OAK ST. EXT.
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605
Mailing Address - Country:US
Mailing Address - Phone:229-241-1188
Mailing Address - Fax:229-245-7106
Practice Address - Street 1:3294 NORTH OAK ST. EXT.
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605
Practice Address - Country:US
Practice Address - Phone:229-247-2290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004094363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA723712955AMedicaid
GA723712955AMedicaid
GA97WCDZVMedicare PIN