Provider Demographics
NPI:1841251386
Name:BRADFORD, SHAYNE D (PA-C)
Entity type:Individual
Prefix:MR
First Name:SHAYNE
Middle Name:D
Last Name:BRADFORD
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 1:25 CROSSROADS DR
Mailing Address - Street 2:SUITE 306
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5421
Mailing Address - Country:US
Mailing Address - Phone:443-738-2872
Mailing Address - Fax:
Practice Address - Street 1:7505 OSLER DR
Practice Address - Street 2:SUITE 506
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-7736
Practice Address - Country:US
Practice Address - Phone:410-581-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001923363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDCN6601OtherR/R MEDICARE GROUP #
MD970005969OtherR/R MEDICARE PROVIDER #
MDKL33E886Medicare PIN
MDKL19258WMedicare PIN
MDKL09E888Medicare PIN
MD970005969OtherR/R MEDICARE PROVIDER #