Provider Demographics
NPI:1942682646
Name:BRADSHAW, ASHLEY ALISSA
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:ALISSA
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 1:1888 ANTILLEY RD STE 200
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79606-1312
Mailing Address - Country:US
Mailing Address - Phone:325-670-6580
Mailing Address - Fax:833-972-0889
Practice Address - Street 1:1888 ANTILLEY RD STE 200
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79606-1312
Practice Address - Country:US
Practice Address - Phone:325-670-6580
Practice Address - Fax:833-972-0889
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-18
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXU5714208600000X
MO2021001794208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5315071441OtherCONTROLLED SUBSTANCE NUMBER