Provider Demographics
NPI:1992765168
Name:BRADSHAW, JONATHAN JAMES (PA-C)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:JAMES
Last Name:BRADSHAW
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:
Other - Last Name:BRADSHAW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:745 CHESTWOOD CHASE DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-2580
Mailing Address - Country:US
Mailing Address - Phone:904-214-6561
Mailing Address - Fax:
Practice Address - Street 1:4500 SAN PABLO RD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-1865
Practice Address - Country:US
Practice Address - Phone:904-953-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9103821363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292826400Medicaid
FLAH506YMedicare PIN