Provider Demographics
NPI:1043477672
Name:BRADSHAW, CHARLES JEREMY (MPAS PA-C)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:JEREMY
Last Name:BRADSHAW
Suffix:
Gender:M
Credentials:MPAS PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1115 BOULDERS PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23225-4067
Mailing Address - Country:US
Mailing Address - Phone:804-327-9242
Mailing Address - Fax:804-327-9812
Practice Address - Street 1:1849 OLD DONATION PKWY
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-3004
Practice Address - Country:US
Practice Address - Phone:757-422-8476
Practice Address - Fax:757-425-8476
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA1081007363A00000X
VA0110003574363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000OtherTRICARE