Provider Demographics
NPI:1639459332
Name:FLETCHER, BRANDON KEITH (PT, DPT, ATC)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:KEITH
Last Name:FLETCHER
Suffix:
Gender:M
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:115 W BROADWAY BLVD
Practice Address - Street 2:STE 300
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-5708
Practice Address - Country:US
Practice Address - Phone:660-827-2945
Practice Address - Fax:660-827-2961
Is Sole Proprietor?:No
Enumeration Date:2011-08-25
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20110303882255A2300X, 2255A2300X
MO2014031708225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA4370088OtherMEDICARE PTAN
51054018OtherBCBS-KC
003525OtherOPTUM
KSKA2868064OtherMEDICARE PTAN