Provider Demographics
NPI:1093320111
Name:WILEY, BRANDON (DPT)
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:
Last Name:WILEY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 GLEN ROYAL DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-2263
Mailing Address - Country:US
Mailing Address - Phone:719-565-6678
Mailing Address - Fax:
Practice Address - Street 1:58 GLEN ROYAL DR
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-2263
Practice Address - Country:US
Practice Address - Phone:719-565-6678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0017231208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation