Provider Demographics
NPI:1598246548
Name:BRAINARD, MAX KYLE
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:KYLE
Last Name:BRAINARD
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 1:1019 SAINT AUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-6752
Mailing Address - Country:US
Mailing Address - Phone:608-514-5261
Mailing Address - Fax:
Practice Address - Street 1:425 PINE RIDGE BLVD STE 211
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4123
Practice Address - Country:US
Practice Address - Phone:715-845-5505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI139116163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse