Provider Demographics
NPI:1295278356
Name:WILLIAMS, BRADEN
Entity type:Individual
Prefix:
First Name:BRADEN
Middle Name:
Last Name:WILLIAMS
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 1:6123 COVENANT DR
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-9524
Mailing Address - Country:US
Mailing Address - Phone:605-430-2492
Mailing Address - Fax:
Practice Address - Street 1:6123 COVENANT DR
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-9524
Practice Address - Country:US
Practice Address - Phone:605-430-2492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-22
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD00969999367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered