| Doctor Name: | BRADSHAW MICHAEL MALLARD |
| NPI Number: | 1003095548 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PA |
| License Number: | 5601001586 |
| Business Practice Address: | 21801 Goddard Rd Wsupg Pm&r Oakwood Taylor, MI - 481804213 |
| Business Phone Number: | 3134387373 |
| Business Fax Number: | 3134387375 |
| Mailing Address: | 1560 E. Maple Rd., Suite 400- Credentialing TROY |
| State: | MI |
| Postal Code: | 480831189 |
| Phone Number: | 7342840865 |
| Fax Number: | 7342841628 |
| NPI Enumeration Date: | 11/01/2007 |
| NPI Last Update Date: | 06/07/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363AM0700X |
| License Number: | 5601001586 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | MI |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Physician Assistant |
| Taxonomy Specialization: | Medical |
| Taxonomy Definition: | |