Provider Demographics
NPI:1720495138
Name:MCDERMOTT, BRENDON
Entity Type:Individual
Prefix:
First Name:BRENDON
Middle Name:
Last Name:MCDERMOTT
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 1:155 N STADIUM DR
Mailing Address - Street 2:HPER 326B
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-4026
Mailing Address - Country:US
Mailing Address - Phone:479-575-4670
Mailing Address - Fax:
Practice Address - Street 1:155 N STADIUM DR
Practice Address - Street 2:HPER 326B
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-4026
Practice Address - Country:US
Practice Address - Phone:479-575-4670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-17
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR0700021282255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer