MEDICARE: JOHN MARTIN BRADSHAW PA-C

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	102830	NC

General Provider Information

NPI Number	:	1588650394
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN MARTIN BRADSHAW PA-C

Provider Business Mailing Address
First Line	:	112 WOODLAWN RD
Second Line	:
City	:	MOUNT HOLLY
State	:	NC
Zip	:	28120-1775
Country	:	US
Telephone Number	:	704-827-3575
Fax Number	:	704-827-0840

Provider Business Practice Location Address
First Line	:	112 WOODLAWN RD
Second Line	:
City	:	MOUNT HOLLY
State	:	NC
Zip	:	28120-1775
Country	:	US
Telephone Number	:	704-827-3575
Fax Number	:	704-827-0840

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

Provider Enumeration Date	:	09/27/2005
Last Update Date	:	10/07/2010

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