Provider Demographics
NPI:1750301115
Name:BRAITHWAITE, WINSLOW PERCIVAL (PA)
Entity Type:Individual
Prefix:
First Name:WINSLOW
Middle Name:PERCIVAL
Last Name:BRAITHWAITE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 NORTHFIELD AVE STE 304
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-5344
Mailing Address - Country:US
Mailing Address - Phone:973-612-2214
Mailing Address - Fax:
Practice Address - Street 1:81 NORTHFIELD AVE STE 304
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-5344
Practice Address - Country:US
Practice Address - Phone:973-612-2214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00046300363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ068389Medicare PIN
NJP84932Medicare UPIN