Healthcare Provider Details

I. General information

NPI: 1942153242
Provider Name (Legal Business Name): BRADEN DWYER RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2026
Last Update Date: 02/17/2026
Certification Date: 02/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3764 SILVERWOOD RD
LAS CRUCES NM
88012-0871
US

IV. Provider business mailing address

3764 SILVERWOOD RD
LAS CRUCES NM
88012-0871
US

V. Phone/Fax

Practice location:
  • Phone: 575-652-7204
  • Fax:
Mailing address:
  • Phone: 575-652-7204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number79551
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: