Basic Information
| Provider Information | |||||||||
| NPI: | 1538625728 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADSHAW | ||||||||
| FirstName: | BRETT | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 CLEARVIEW AVE STE 111 | ||||||||
| Address2: | |||||||||
| City: | DORAVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303402137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702464446 | ||||||||
| FaxNumber: | 7704513343 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 CLEARVIEW AVE STE 111 | ||||||||
| Address2: | |||||||||
| City: | DORAVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303402137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702464446 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2019 | ||||||||
| LastUpdateDate: | 02/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | NCO-000001 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.