Provider Demographics
NPI:1811146541
Name:WILT, BRANDON JASON
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:JASON
Last Name:WILT
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:BRANDON
Other - Middle Name:JASON
Other - Last Name:WILT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:138 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:PA
Mailing Address - Zip Code:15537-7028
Mailing Address - Country:US
Mailing Address - Phone:814-623-6191
Mailing Address - Fax:814-623-5519
Practice Address - Street 1:138 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:PA
Practice Address - Zip Code:15537-7028
Practice Address - Country:US
Practice Address - Phone:814-623-6191
Practice Address - Fax:814-623-5519
Is Sole Proprietor?:No
Enumeration Date:2008-09-18
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC006021213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist