Provider Demographics
NPI:1205595527
Name:FLETCHER, BRANDON
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:FLETCHER
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 1:849 TEAL RD N
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25405-8388
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:181 ROARING LION DR
Practice Address - Street 2:
Practice Address - City:HEDGESVILLE
Practice Address - State:WV
Practice Address - Zip Code:25427-5965
Practice Address - Country:US
Practice Address - Phone:304-754-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-14
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPTA002607225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVPTA002607OtherPHYSICAL THERAPY ASSISTANT