Provider Demographics
NPI:1942030564
Name:BRADSHAW, MADISON KELLEY
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:KELLEY
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2004 GRAHAM AVE
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74361-4552
Mailing Address - Country:US
Mailing Address - Phone:918-384-8010
Mailing Address - Fax:
Practice Address - Street 1:6216 S LEWIS AVE # ATE102
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1044
Practice Address - Country:US
Practice Address - Phone:918-268-7179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-07
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator