Provider Demographics
NPI:1538625728
Name:BRADSHAW, BRETT J (NP)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:J
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 CLEARVIEW AVE STE 111
Mailing Address - Street 2:
Mailing Address - City:DORAVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30340-2137
Mailing Address - Country:US
Mailing Address - Phone:770-246-4446
Mailing Address - Fax:770-451-3343
Practice Address - Street 1:2000 CLEARVIEW AVE STE 111
Practice Address - Street 2:
Practice Address - City:DORAVILLE
Practice Address - State:GA
Practice Address - Zip Code:30340-2137
Practice Address - Country:US
Practice Address - Phone:770-246-4446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-13
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GANCO-000001363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner