Provider Demographics
NPI:1215007661
Name:BRAYSHAW, ALICE E (PA-C)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:E
Last Name:BRAYSHAW
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 991950
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96099-1950
Mailing Address - Country:US
Mailing Address - Phone:530-246-2467
Mailing Address - Fax:530-242-9460
Practice Address - Street 1:1255 LIBERTY STREET
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-0814
Practice Address - Country:US
Practice Address - Phone:530-246-2467
Practice Address - Fax:530-242-9460
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18032363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA18032OtherPA LICENSE NUMBER
CA680310525OtherTAX ID
CAGR0079250Medicaid
CAZZZ44371ZMedicare PIN