Provider Demographics
NPI:1902809734
Name:BRAXTON, JOHN S III (PA)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:S
Last Name:BRAXTON
Suffix:III
Gender:M
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:CONOWINGO
Mailing Address - State:MD
Mailing Address - Zip Code:21918-0099
Mailing Address - Country:US
Mailing Address - Phone:410-378-9696
Mailing Address - Fax:410-378-9922
Practice Address - Street 1:253 LEWIS LN
Practice Address - Street 2:SUITE 202
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078-3750
Practice Address - Country:US
Practice Address - Phone:443-502-7060
Practice Address - Fax:410-378-9922
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDC0000645363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP01967Medicare UPIN
MD852L125EMedicare ID - Type UnspecifiedMEDICARE #