Provider Demographics
NPI:1184189367
Name:ARCHER, BRANDON (PTA)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:ARCHER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5618 WESLO WILLOW CIR APT 312
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27409-1741
Mailing Address - Country:US
Mailing Address - Phone:336-688-7140
Mailing Address - Fax:
Practice Address - Street 1:3801 WADE COBLE DR
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-9765
Practice Address - Country:US
Practice Address - Phone:336-538-1522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6817225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant