Provider Demographics
NPI:1609893676
Name:BRADSHAW, JERRI (PA-C)
Entity Type:Individual
Prefix:
First Name:JERRI
Middle Name:
Last Name:BRADSHAW
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 1:3776 DOGWOOD RD
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-7953
Mailing Address - Country:US
Mailing Address - Phone:580-302-4447
Mailing Address - Fax:
Practice Address - Street 1:1306 12TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1285
Practice Address - Country:US
Practice Address - Phone:580-223-6003
Practice Address - Fax:580-223-6999
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1402363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200076780Medicaid
OKQ56640Medicare UPIN