Provider Demographics
NPI:1932284338
Name:BRAYSHAW, JEFFREY L (PA)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:L
Last Name:BRAYSHAW
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4201
Mailing Address - Country:US
Mailing Address - Phone:209-521-6097
Mailing Address - Fax:
Practice Address - Street 1:1501 OAKDALE RD
Practice Address - Street 2:SUITE 218
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-3381
Practice Address - Country:US
Practice Address - Phone:209-572-4222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17131363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA17131OtherPHYSICIAN ASSISTANT
CAQ06514Medicare UPIN
CABL496YMedicare PIN
CAZZZ92354ZMedicare Oscar/Certification