Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207P00000X | Emergency Physician | OS12519 | FL |
N | 207QA0401X | Family Doctor - Addiction Medicine | OS12519 | FL |
N | 208D00000X | General Practice Physician | OS12519 | FL |
NPI | 1902044985 |
---|---|
Provider Name | Beau Braden |
First Address | Ave Maria, FL 34142-9505 |
Second Address | Ave Maria, FL 34142-9505 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/01/2009 |
Last Update Date | 28/11/2016 |