MEDICARE: BRANDEN WAYNE RAIDER RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WE0003X	Emergency Registered Nurse	1159821	KY

General Provider Information

NPI Number	:	1326809104
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDEN WAYNE RAIDER RN

Provider Business Mailing Address
First Line	:	5913 ELDORADO AVE
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40291-1350
Country	:	US
Telephone Number	:	859-559-5194
Fax Number	:

Provider Business Practice Location Address
First Line	:	5913 ELDORADO AVE
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40291-1350
Country	:	US
Telephone Number	:	859-559-5194
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/19/2024
Last Update Date	:	01/19/2024

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