Individual
MR. JOHNNIE MACK BRADSHAW
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
2001 RANDOLPH RD, CHARLOTTE, NC 28207-1215
(704) 323-2000
Mailing address
4601 PARK RD, SUITE 300, CHARLOTTE, NC 28209-3239
(704) 323-2000
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
100701
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
100701
NC MEDICAL LICENSE
NC
Enumeration date
09/15/2006
Last updated
02/28/2014
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