Provider Demographics
NPI:1932441003
Name:BAUMGARDNER, BRANDON JASON (MSOTR/L)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:JASON
Last Name:BAUMGARDNER
Suffix:
Gender:M
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 PEPPERS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-2070
Mailing Address - Country:US
Mailing Address - Phone:276-223-5400
Mailing Address - Fax:276-223-5454
Practice Address - Street 1:165 PEPPERS FERRY RD
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-2070
Practice Address - Country:US
Practice Address - Phone:276-223-5400
Practice Address - Fax:276-223-5454
Is Sole Proprietor?:No
Enumeration Date:2013-03-26
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119005285225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0119005285OtherVIRGINIA