Healthcare Provider Details

I. General information

NPI: 1114413606
Provider Name (Legal Business Name): BRADEN LEE ALLRED PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2018
Last Update Date: 08/24/2021
Certification Date: 08/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 BLUE RIDGE RD STE 300
RALEIGH NC
27607-6476
US

IV. Provider business mailing address

2800 BLUE RIDGE RD STE 300
RALEIGH NC
27607-6476
US

V. Phone/Fax

Practice location:
  • Phone: 919-784-7874
  • Fax:
Mailing address:
  • Phone: 919-784-7874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0010-08108
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-08108
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: