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General NPI Number Information
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NPI Number | 1043477672
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Entity Type | Individual
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Provider Name | CHARLES JEREMY BRADSHAW MPAS PA-C
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Gender | Male
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Dates
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Enumeration Date | 05/21/2008
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Last Update Date | 05/18/2020
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Provider Practice Location Address
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Address Line | 1849 OLD DONATION PKWY
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City | VIRGINIA BEACH
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State | VA
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Zip | 23454-3004
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Country | US
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Telephone | 757-422-8476
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Fax | 757-425-8476
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Provider Business Mailing Address
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Address Line | 1115 BOULDERS PKWY STE 200
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City | NORTH CHESTERFIELD
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State | VA
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Zip | 23225-4067
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Country | US
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Telephone | 804-327-9242
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Fax | 804-327-9812
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 1081007
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 0110003574
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License Number State | VA
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