Provider Demographics
NPI:1588650394
Name:BRADSHAW, JOHN MARTIN (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MARTIN
Last Name:BRADSHAW
Suffix:
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 1:112 WOODLAWN RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOLLY
Mailing Address - State:NC
Mailing Address - Zip Code:28120-1775
Mailing Address - Country:US
Mailing Address - Phone:704-827-3575
Mailing Address - Fax:704-827-0840
Practice Address - Street 1:112 WOODLAWN RD
Practice Address - Street 2:
Practice Address - City:MOUNT HOLLY
Practice Address - State:NC
Practice Address - Zip Code:28120-1775
Practice Address - Country:US
Practice Address - Phone:704-827-3575
Practice Address - Fax:704-827-0840
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102830363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCS90508Medicare UPIN
NC2752634AMedicare ID - Type Unspecified