Provider Demographics
NPI:1982830584
Name:SHUPE, BRADLEY ALAN (DPT)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:ALAN
Last Name:SHUPE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12414 HURLOCK DR
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-3708
Mailing Address - Country:US
Mailing Address - Phone:260-348-4993
Mailing Address - Fax:
Practice Address - Street 1:12414 HURLOCK DR
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-3708
Practice Address - Country:US
Practice Address - Phone:260-348-4993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-09
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99037889A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01380357Medicare PIN
INM400055802Medicare PIN