Provider Demographics
NPI:1205447216
Name:BRAUTIGAM, SIRAH NICOLE
Entity type:Individual
Prefix:
First Name:SIRAH
Middle Name:NICOLE
Last Name:BRAUTIGAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 TABLE ROCK RD APT 23
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-1458
Mailing Address - Country:US
Mailing Address - Phone:541-690-0521
Mailing Address - Fax:
Practice Address - Street 1:2120 TABLE ROCK RD APT 23
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-1458
Practice Address - Country:US
Practice Address - Phone:541-690-0521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant