Healthcare Provider Details

I. General information

NPI: 1790111813
Provider Name (Legal Business Name): BRITTANY BRADSHAW BASCOM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2013
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2118 SW 20TH PL STE 102
OCALA FL
34471-0869
US

IV. Provider business mailing address

13020 N TELECOM PKWY
TEMPLE TERRACE FL
33637-0925
US

V. Phone/Fax

Practice location:
  • Phone: 352-647-9700
  • Fax:
Mailing address:
  • Phone: 813-978-9700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1107608
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: