Provider Demographics
NPI:1104307719
Name:GLADYSZ, BRADEN
Entity type:Individual
Prefix:
First Name:BRADEN
Middle Name:
Last Name:GLADYSZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 SHADY AVE
Mailing Address - Street 2:GREENVILLE MEDICAL CENTER
Mailing Address - City:GREENVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16125-1822
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1599 N HERMITAGE RD
Practice Address - Street 2:GREENVILLE MEDICAL CENTER
Practice Address - City:HERMITAGE
Practice Address - State:PA
Practice Address - Zip Code:16148-3180
Practice Address - Country:US
Practice Address - Phone:724-962-9622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA004513363A00000X
PAMA059862363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant