Provider Demographics
NPI:1659905107
Name:COOPER, BRAEDEN MICAH (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BRAEDEN
Middle Name:MICAH
Last Name:COOPER
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8510 E 29TH ST N APT 705
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-6614
Mailing Address - Country:US
Mailing Address - Phone:316-259-0755
Mailing Address - Fax:
Practice Address - Street 1:10100 E SHANNON WOODS CIR
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-4104
Practice Address - Country:US
Practice Address - Phone:316-462-7450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-24
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
KS11-07427225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer