Provider Demographics
NPI:1063986222
Name:OTT, BRAEDEN BAKER
Entity type:Individual
Prefix:
First Name:BRAEDEN
Middle Name:BAKER
Last Name:OTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 N GREECE RD
Mailing Address - Street 2:
Mailing Address - City:HILTON
Mailing Address - State:NY
Mailing Address - Zip Code:14468-8914
Mailing Address - Country:US
Mailing Address - Phone:585-465-7399
Mailing Address - Fax:
Practice Address - Street 1:44 N GREECE RD
Practice Address - Street 2:
Practice Address - City:HILTON
Practice Address - State:NY
Practice Address - Zip Code:14468-8914
Practice Address - Country:US
Practice Address - Phone:585-465-7399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-21
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer