Provider Demographics
NPI:1083225023
Name:BRADSHAW, SHELBY (PA)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 LAS BRISAS DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-5812
Mailing Address - Country:US
Mailing Address - Phone:940-210-5097
Mailing Address - Fax:
Practice Address - Street 1:1004 HOBBS HWY STE 4
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:TX
Practice Address - Zip Code:79360-3310
Practice Address - Country:US
Practice Address - Phone:432-758-4777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-13
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA16156363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant