Provider Demographics
NPI:1619960804
Name:BRADEN, JOE MCKINLEY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JOE
Middle Name:MCKINLEY
Last Name:BRADEN
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 1:282 APOLLO BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:APOLLO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33572-2261
Mailing Address - Country:US
Mailing Address - Phone:813-645-4068
Mailing Address - Fax:813-645-0312
Practice Address - Street 1:282 APOLLO BEACH BLVD
Practice Address - Street 2:
Practice Address - City:APOLLO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33572-2261
Practice Address - Country:US
Practice Address - Phone:813-645-4068
Practice Address - Fax:813-645-0312
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101501363A00000X
TN1510363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S64934Medicare UPIN
FLE5409WMedicare ID - Type Unspecified