Healthcare Provider Details

I. General information

NPI: 1255315396
Provider Name (Legal Business Name): BRADEN ALAN SHOUPE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LANDSTUHL REGIONAL MEDICAL CENTER BLDG 3767 (9A)
APO AE
09810
DE

IV. Provider business mailing address

3700 FETTLER PARK DR
DUMFRIES VA
22025-2050
DE

V. Phone/Fax

Practice location:
  • Phone: 011496371865300
  • Fax: 011496371868192
Mailing address:
  • Phone: 703-441-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number31072
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: