MEDICARE: SHANNA POLLOCK BRADSHAW PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	103392	NC

General Provider Information

NPI Number	:	1265514087
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNA POLLOCK BRADSHAW PA

Provider Business Mailing Address
First Line	:	PO BOX 19305
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28219-9305
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7910 US HWY 117 S
Second Line	:	UNIT 120
City	:	ROCKY POINT
State	:	NC
Zip	:	28457-9431
Country	:	US
Telephone Number	:	910-300-4500
Fax Number	:	910-550-3787

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	03/18/2025

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