Healthcare Provider Details

I. General information

NPI: 1356502736
Provider Name (Legal Business Name): ANISSA BRADDOCK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANISSA MURE PA-C

II. Dates (important events)

Enumeration Date: 06/19/2008
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 CAPITAL WAY STE 356
PENNINGTON NJ
08534
US

IV. Provider business mailing address

2 CAPITAL WAY STE 456
PENNINGTON NJ
08534-2521
US

V. Phone/Fax

Practice location:
  • Phone: 609-537-7277
  • Fax: 609-537-6002
Mailing address:
  • Phone: 609-537-7277
  • Fax: 609-537-6002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number25MP00149200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: