Healthcare Provider Details

I. General information

NPI: 1467211318
Provider Name (Legal Business Name): BRENDAN WICAKASOTA WHITEBIRD RN-BSN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2024
Last Update Date: 03/14/2024
Certification Date: 03/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 CANYON LAKE DR
RAPID CITY SD
57702-8114
US

IV. Provider business mailing address

3200 CANYON LAKE DR
RAPID CITY SD
57702-8114
US

V. Phone/Fax

Practice location:
  • Phone: 605-355-2500
  • Fax:
Mailing address:
  • Phone: 605-355-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License NumberR058640
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: