Provider Demographics
NPI:1235192774
Name:BRADSHAW, EDWARD WILLARD III (PA-C)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:WILLARD
Last Name:BRADSHAW
Suffix:III
Gender:M
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 1:72 LAKE HAVASU AVE S STE 102
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-0857
Mailing Address - Country:US
Mailing Address - Phone:928-453-2211
Mailing Address - Fax:928-453-2219
Practice Address - Street 1:72 LAKE HAVASU AVE S STE 102
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-0857
Practice Address - Country:US
Practice Address - Phone:928-453-2211
Practice Address - Fax:928-453-2213
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2576363AS0400X
AZ5357363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ040403Medicaid
FL291637100Medicaid
P00221346OtherRAILROAD MEDICARE
AZZ179746Medicare PIN
P00221346OtherRAILROAD MEDICARE
AZ040403Medicaid
FLU1420XMedicare PIN
S85281Medicare UPIN