Provider Demographics
NPI:1073086005
Name:SHIELDS, BRADLEY KEITH
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:KEITH
Last Name:SHIELDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 EARL CLARK DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:MS
Mailing Address - Zip Code:39073-6604
Mailing Address - Country:US
Mailing Address - Phone:601-891-8465
Mailing Address - Fax:601-891-8468
Practice Address - Street 1:128 EARL CLARK DR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:MS
Practice Address - Zip Code:39073-6604
Practice Address - Country:US
Practice Address - Phone:601-891-8465
Practice Address - Fax:601-891-8468
Is Sole Proprietor?:No
Enumeration Date:2019-01-02
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903096363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner