Provider Demographics
NPI:1841716628
Name:DAVIS, BRANDON THOMAS (PTA)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:THOMAS
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 MARCH CT APT D
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28405-3571
Mailing Address - Country:US
Mailing Address - Phone:910-902-3167
Mailing Address - Fax:
Practice Address - Street 1:3800 INDEPENDENCE BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-2599
Practice Address - Country:US
Practice Address - Phone:910-444-0513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2017-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA6010225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant