Provider Demographics
NPI:1902044985
Name:BRADEN, BEAU
Entity Type:Individual
Prefix:
First Name:BEAU
Middle Name:
Last Name:BRADEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 AVE MARIA BLVD
Mailing Address - Street 2:
Mailing Address - City:AVE MARIA
Mailing Address - State:FL
Mailing Address - Zip Code:34142-9505
Mailing Address - Country:US
Mailing Address - Phone:239-867-4395
Mailing Address - Fax:239-217-3662
Practice Address - Street 1:5050 AVE MARIA BLVD
Practice Address - Street 2:
Practice Address - City:AVE MARIA
Practice Address - State:FL
Practice Address - Zip Code:34142-9505
Practice Address - Country:US
Practice Address - Phone:239-867-4395
Practice Address - Fax:239-217-3662
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-28
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS12519207PT0002X, 207P00000X, 208D00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PT0002XAllopathic & Osteopathic PhysiciansEmergency MedicineMedical Toxicology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine