Provider Demographics
NPI:1356502736
Name:BRADDOCK, ANISSA (PA-C)
Entity Type:Individual
Prefix:
First Name:ANISSA
Middle Name:
Last Name:BRADDOCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANISSA
Other - Middle Name:
Other - Last Name:MURE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2 CAPITAL WAY STE 356
Mailing Address - Street 2:
Mailing Address - City:PENNINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08534-2521
Mailing Address - Country:US
Mailing Address - Phone:609-537-7277
Mailing Address - Fax:609-537-6002
Practice Address - Street 1:2 CAPITAL WAY STE 356
Practice Address - Street 2:
Practice Address - City:PENNINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08534
Practice Address - Country:US
Practice Address - Phone:609-537-7277
Practice Address - Fax:609-537-6002
Is Sole Proprietor?:No
Enumeration Date:2008-06-19
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00149200363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ260762C04Medicare PIN