Provider Demographics
NPI:1053760611
Name:WALCOTT-AYERS, BRANDON (ATC)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:WALCOTT-AYERS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3755 SE 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-3713
Mailing Address - Country:US
Mailing Address - Phone:925-212-1093
Mailing Address - Fax:
Practice Address - Street 1:345 MONMOUTH AVE N
Practice Address - Street 2:
Practice Address - City:MONMOUTH
Practice Address - State:OR
Practice Address - Zip Code:97361-1329
Practice Address - Country:US
Practice Address - Phone:503-838-8251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-05
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20000242402255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer