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General NPI Number Information
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NPI Number | 1003178450
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Entity Type | Individual
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Provider Name | JASON DEREK BRADSHAW FNP-C
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Gender | Male
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Dates
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Enumeration Date | 06/12/2012
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Last Update Date | 06/12/2012
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Provider Practice Location Address
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Address Line | 1901 S 1ST ST
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City | TEMPLE
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State | TX
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Zip | 76504-7451
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Country | US
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Telephone | 254-743-0714
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Fax |
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Provider Business Mailing Address
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Address Line | 4006 FOUNTAINWOOD CIR
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City | GEORGETOWN
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State | TX
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Zip | 78633-1911
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Country | US
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Telephone | 512-635-2759
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 687070
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License Number State | TX
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