Provider Demographics
NPI:1700354792
Name:EDWARDS, BRANDON LEE (COTA/L, PA-C)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:LEE
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:COTA/L, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 EDGEWATER ST NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-4049
Mailing Address - Country:US
Mailing Address - Phone:503-378-7526
Mailing Address - Fax:
Practice Address - Street 1:1233 EDGEWATER ST NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-4049
Practice Address - Country:US
Practice Address - Phone:503-378-7526
Practice Address - Fax:503-480-1611
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR363AM0700X
224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant