Healthcare Provider Details

I. General information

NPI: 1639849649
Provider Name (Legal Business Name): ANDREW LOREN BRAATEN P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2021
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

628 E 12TH ST
WASHINGTON NC
27889-3409
US

IV. Provider business mailing address

PO BOX 751069
CHARLOTTE NC
28275-1069
US

V. Phone/Fax

Practice location:
  • Phone: 252-975-4319
  • Fax: 252-948-4826
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-12248
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: