Provider Demographics
NPI:1821579012
Name:BRADSHAW, JESSE G (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:G
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 1:243 CHENEY DR W STE 200
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-4278
Mailing Address - Country:US
Mailing Address - Phone:208-647-0656
Mailing Address - Fax:208-647-0659
Practice Address - Street 1:1252 BENNETT AVE STE B
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2664
Practice Address - Country:US
Practice Address - Phone:208-647-0656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-24
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA1467363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant