Provider Demographics
NPI:1508564634
Name:BRAXTON, MATHIEU (STUDENT)
Entity Type:Individual
Prefix:
First Name:MATHIEU
Middle Name:
Last Name:BRAXTON
Suffix:
Gender:M
Credentials:STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3330 MERIDIAN ST N APT 207
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35811-1589
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4900 MERIDIAN ST N
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35811-1156
Practice Address - Country:US
Practice Address - Phone:256-372-4710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-17
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program