Provider Demographics
NPI:1679782171
Name:BRADLEY, SHANE PATRICK (DC)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:PATRICK
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4461 TAMARA LN
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50265-6973
Mailing Address - Country:US
Mailing Address - Phone:515-650-7599
Mailing Address - Fax:
Practice Address - Street 1:409 WILSON ST
Practice Address - Street 2:
Practice Address - City:VAN METER
Practice Address - State:IA
Practice Address - Zip Code:50261-9728
Practice Address - Country:US
Practice Address - Phone:515-650-7599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06587111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI12015OtherWELLMARK BCBS
IA18952Medicare ID - Type Unspecified