Provider Demographics
NPI:1992789846
Name:BRADSHAW, ALLISON LYNN (PA)
Entity type:Individual
Prefix:MS
First Name:ALLISON
Middle Name:LYNN
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 MAIN CIR STE 1
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH AFB
Mailing Address - State:TX
Mailing Address - Zip Code:78150-4543
Mailing Address - Country:US
Mailing Address - Phone:701-721-1500
Mailing Address - Fax:
Practice Address - Street 1:221 3RD ST W
Practice Address - Street 2:BUILDING 1040
Practice Address - City:RANDOLPH AFB
Practice Address - State:TX
Practice Address - Zip Code:78150-4800
Practice Address - Country:US
Practice Address - Phone:701-723-5199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1068209363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant