Provider Demographics
NPI:1881621829
Name:BRADEN, LISA A (PA-C)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:BRADEN
Suffix:
Gender:F
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:PO BOX 79777
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279-0777
Mailing Address - Country:US
Mailing Address - Phone:434-654-7794
Mailing Address - Fax:434-654-5574
Practice Address - Street 1:595 MARTHA JEFFERSON DR STE 180
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-4669
Practice Address - Country:US
Practice Address - Phone:434-654-5575
Practice Address - Fax:434-654-5574
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840316363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVD806BMedicare PIN
VA970013362OtherPALMETTO GBA RR MEDICARE