MEDICARE: BRANDON PORTER ATC

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	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1760174965
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDON PORTER ATC

Provider Business Mailing Address
First Line	:	2939 N 36TH ST APT 211
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85018-7460
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2939 N 36TH ST APT 211
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85018-7460
Country	:	US
Telephone Number	:	815-412-0239
Fax Number	:

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

Provider Enumeration Date	:	05/24/2023
Last Update Date	:	05/24/2023

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