Provider Demographics
NPI:1811201957
Name:WALKER, BRANDON
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:WALKER
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 1:8170 33RD AVE S - PO BOX 1309
Mailing Address - Street 2:MS 21110Q
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:651-265-0000
Mailing Address - Fax:651-265-0001
Practice Address - Street 1:2004 FORD PARKWAY
Practice Address - Street 2:MS 35300A
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-1931
Practice Address - Country:US
Practice Address - Phone:651-265-0000
Practice Address - Fax:651-265-0001
Is Sole Proprietor?:No
Enumeration Date:2010-07-30
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN11262363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program