Provider Demographics
NPI:1194094516
Name:BRADSHAW, BRANDON LEE I
Entity type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:LEE
Last Name:BRADSHAW
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1431 CABLE RANCH RD APT 1811
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78245-2138
Mailing Address - Country:US
Mailing Address - Phone:210-473-5777
Mailing Address - Fax:
Practice Address - Street 1:1431 CABLE RANCH RD APT 1811
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78245-2138
Practice Address - Country:US
Practice Address - Phone:210-473-5777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-14
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80-0722004251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health