Provider Demographics
NPI:1043791668
Name:CHILDERS, BRAXTON S (PA)
Entity Type:Individual
Prefix:
First Name:BRAXTON
Middle Name:S
Last Name:CHILDERS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:211 EXECUTIVE DR STE 11
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19702-3358
Mailing Address - Country:US
Mailing Address - Phone:302-731-2888
Mailing Address - Fax:302-731-7049
Practice Address - Street 1:4102 OGLETOWN STANTON RD STE B
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-4183
Practice Address - Country:US
Practice Address - Phone:302-731-2888
Practice Address - Fax:302-731-7049
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE363A00000X
TN3606363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant