Provider Demographics
NPI:1548801137
Name:THOMPSON, BRANDON WAYNELL (PTA)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:WAYNELL
Last Name:THOMPSON
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 1:40 PINE RIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:ARDEN
Mailing Address - State:NC
Mailing Address - Zip Code:28704-7703
Mailing Address - Country:US
Mailing Address - Phone:704-533-4776
Mailing Address - Fax:
Practice Address - Street 1:3864 SWEETEN CREEK RD
Practice Address - Street 2:
Practice Address - City:ARDEN
Practice Address - State:NC
Practice Address - Zip Code:28704-3136
Practice Address - Country:US
Practice Address - Phone:828-681-0904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA5721225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant