Provider Demographics
NPI:1770254138
Name:CHILDERS, BRADEN
Entity Type:Individual
Prefix:
First Name:BRADEN
Middle Name:
Last Name:CHILDERS
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:PO BOX 624
Mailing Address - Street 2:
Mailing Address - City:PORT ROYAL
Mailing Address - State:SC
Mailing Address - Zip Code:29935-0624
Mailing Address - Country:US
Mailing Address - Phone:843-384-1395
Mailing Address - Fax:
Practice Address - Street 1:955 RIBAUT RD
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-5441
Practice Address - Country:US
Practice Address - Phone:888-537-8533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-24
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25693367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered