Healthcare Provider Details

I. General information

NPI: 1548991045
Provider Name (Legal Business Name): BRAIDEN R SHUMWAY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2022
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2454 N 25TH E STE 101
IDAHO FALLS ID
83401-1050
US

IV. Provider business mailing address

PO BOX 18
SAINT ANTHONY ID
83445-0018
US

V. Phone/Fax

Practice location:
  • Phone: 208-356-4900
  • Fax: 208-612-6118
Mailing address:
  • Phone: 208-356-4900
  • Fax: 208-624-4112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5581812
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberUO8646
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: