Provider Demographics
NPI:1598447070
Name:IMEL, BRAYDEN SQUIRE (PA-C)
Entity Type:Individual
Prefix:
First Name:BRAYDEN
Middle Name:SQUIRE
Last Name:IMEL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3308 POLO CLUB BLVD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-8531
Mailing Address - Country:US
Mailing Address - Phone:606-627-3283
Mailing Address - Fax:
Practice Address - Street 1:740 S LIMESTONE STE L119
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0001
Practice Address - Country:US
Practice Address - Phone:859-257-3253
Practice Address - Fax:859-323-1203
Is Sole Proprietor?:No
Enumeration Date:2023-08-03
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC054363A00000X, 363AM0700X, 363AS0400X
KYPA3291363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical