Provider Demographics
NPI:1902540479
Name:STILLWAGON, BRAYDEN MONTGOMERY
Entity Type:Individual
Prefix:
First Name:BRAYDEN
Middle Name:MONTGOMERY
Last Name:STILLWAGON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 STACEY XING
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-9640
Mailing Address - Country:US
Mailing Address - Phone:304-551-1223
Mailing Address - Fax:
Practice Address - Street 1:42 JENNA WAY
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-5600
Practice Address - Country:US
Practice Address - Phone:304-551-5447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care