Healthcare Provider Details

I. General information

NPI: 1225601446
Provider Name (Legal Business Name): BRADY BAKER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2021
Last Update Date: 05/24/2023
Certification Date: 04/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2865 CHANCELLOR DR STE 225
CRESTVIEW HILLS KY
41017-3915
US

IV. Provider business mailing address

2865 CHANCELLOR DR STE 225
CRESTVIEW HILLS KY
41017-3915
US

V. Phone/Fax

Practice location:
  • Phone: 859-341-5400
  • Fax:
Mailing address:
  • Phone: 859-341-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberPA2794
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2794
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: