Provider Demographics
NPI:1083325229
Name:PAGE, BRAEDEN STEVEN ALLEN
Entity Type:Individual
Prefix:
First Name:BRAEDEN
Middle Name:STEVEN ALLEN
Last Name:PAGE
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 1:30636 BROWNLEE RD
Mailing Address - Street 2:
Mailing Address - City:RAINIER
Mailing Address - State:OR
Mailing Address - Zip Code:97048-3701
Mailing Address - Country:US
Mailing Address - Phone:503-396-0823
Mailing Address - Fax:
Practice Address - Street 1:58646 MCNULTY WAY
Practice Address - Street 2:
Practice Address - City:SAINT HELENS
Practice Address - State:OR
Practice Address - Zip Code:97051-6210
Practice Address - Country:US
Practice Address - Phone:503-396-0823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-08
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR107842175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist