Provider Demographics
NPI:1588660773
Name:BRADSHAW, LEE W (APRN)
Entity Type:Individual
Prefix:MR
First Name:LEE
Middle Name:W
Last Name:BRADSHAW
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-387-5600
Mailing Address - Fax:801-475-4720
Practice Address - Street 1:3903 HARRISON BLVD
Practice Address - Street 2:#300
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-8440
Practice Address - Country:US
Practice Address - Phone:801-387-4930
Practice Address - Fax:801-387-9470
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6242996-4405364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health