Provider Demographics
NPI:1205193216
Name:BRADSHAW, DEANDRE' ANTONIO
Entity Type:Individual
Prefix:
First Name:DEANDRE'
Middle Name:ANTONIO
Last Name:BRADSHAW
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 1:1111 OCEANVIEW DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99515-3906
Mailing Address - Country:US
Mailing Address - Phone:907-230-1172
Mailing Address - Fax:
Practice Address - Street 1:1111 OCEANVIEW DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515-3906
Practice Address - Country:US
Practice Address - Phone:907-230-1172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-13
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider