Healthcare Provider Details

I. General information

NPI: 1093212920
Provider Name (Legal Business Name): BRADY JAMES HOLDAWAY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2018
Last Update Date: 03/20/2026
Certification Date: 03/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E 20TH ST STE 200
CHEYENNE WY
82001-3880
US

IV. Provider business mailing address

PO BOX 20970
CHEYENNE WY
82003-7020
US

V. Phone/Fax

Practice location:
  • Phone: 307-633-7444
  • Fax: 307-996-1595
Mailing address:
  • Phone: 307-996-4777
  • Fax: 307-773-8013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number17998
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number14235A
License Number StateWY
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberDR.0065859
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: