Healthcare Provider Details

I. General information

NPI: 1336536697
Provider Name (Legal Business Name): BRANDON BRADDOCK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2015
Last Update Date: 05/31/2024
Certification Date: 05/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HEALTH PARK BLVD SUITE 4000
SAINT AUGUSTINE FL
32086-3707
US

IV. Provider business mailing address

607 PEGGY PL
SAINT AUGUSTINE FL
32086-7199
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-8666
  • Fax:
Mailing address:
  • Phone: 904-540-5454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9108661
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: