Provider Demographics
NPI:1588110480
Name:BRADDIX, DEREK CHRISTOPHER
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:CHRISTOPHER
Last Name:BRADDIX
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 1:1119 MISSISSIPPI AVE APT 115
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-2457
Mailing Address - Country:US
Mailing Address - Phone:314-323-5316
Mailing Address - Fax:
Practice Address - Street 1:9717 LANDMARK PARKWAY DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1628
Practice Address - Country:US
Practice Address - Phone:775-423-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-30
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016025007363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily