Provider Demographics
NPI:1265514087
Name:BRADSHAW, SHANNA POLLOCK (PA)
Entity type:Individual
Prefix:
First Name:SHANNA
Middle Name:POLLOCK
Last Name:BRADSHAW
Suffix:
Gender:
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7910 US HWY 117 S
Practice Address - Street 2:UNIT 120
Practice Address - City:ROCKY POINT
Practice Address - State:NC
Practice Address - Zip Code:28457-9431
Practice Address - Country:US
Practice Address - Phone:910-300-4500
Practice Address - Fax:910-550-3787
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103392363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1265514087Medicaid
NC2753823CMedicare PIN
NC1265514087Medicaid
NC2753823KMedicare PIN
P43875Medicare UPIN