Provider Demographics
NPI:1003473315
Name:BRADSHER, LORI NICOLE (PTA)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:NICOLE
Last Name:BRADSHER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11200 GOVERNOR MANLY WAY STE 309
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-7375
Mailing Address - Country:US
Mailing Address - Phone:919-562-9410
Mailing Address - Fax:919-562-2948
Practice Address - Street 1:11200 GOVERNOR MANLY WAY STE 305
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-7383
Practice Address - Country:US
Practice Address - Phone:919-562-9410
Practice Address - Fax:919-562-2948
Is Sole Proprietor?:No
Enumeration Date:2019-05-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant