Provider Demographics
NPI:1053053637
Name:KHOR, BRANDON
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:KHOR
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 1:4219 SW MAWRCREST AVE
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97080-8682
Mailing Address - Country:US
Mailing Address - Phone:503-545-4405
Mailing Address - Fax:
Practice Address - Street 1:520 N 12TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5064
Practice Address - Country:US
Practice Address - Phone:804-828-9190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-12
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0442000453390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program