MEDICARE: BRANDON WENGER DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	2305212295	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2305212295	OTHER	VA	LICENSE

General Provider Information

NPI Number	:	1548740350
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDON WENGER DPT

Provider Business Mailing Address
First Line	:	4229 LAFAYETTE CENTER DR STE 1250
Second Line	:
City	:	CHANTILLY
State	:	VA
Zip	:	20151-1266
Country	:	US
Telephone Number	:	703-263-2020
Fax Number	:

Provider Business Practice Location Address
First Line	:	4229 LAFAYETTE CENTER DR STE 1250
Second Line	:
City	:	CHANTILLY
State	:	VA
Zip	:	20151-1266
Country	:	US
Telephone Number	:	703-263-2020
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2018
Last Update Date	:	10/02/2024

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