Healthcare Provider Details

I. General information

NPI: 1841251386
Provider Name (Legal Business Name): SHAYNE D BRADFORD PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 05/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7505 OSLER DR SUITE 506
TOWSON MD
21204-7736
US

IV. Provider business mailing address

25 CROSSROADS DR SUITE 306
OWINGS MILLS MD
21117-5421
US

V. Phone/Fax

Practice location:
  • Phone: 410-581-1600
  • Fax:
Mailing address:
  • Phone: 443-738-2872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberC0001923
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierCN6601
Identifier TypeOTHER
Identifier StateMD
Identifier IssuerR/R MEDICARE GROUP #
# 2
Identifier970005969
Identifier TypeOTHER
Identifier StateMD
Identifier IssuerR/R MEDICARE PROVIDER #

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: