Healthcare Provider Details

I. General information

NPI: 1811201957
Provider Name (Legal Business Name): BRANDON WALKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2010
Last Update Date: 01/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2004 FORD PARKWAY MS 35300A
ST. PAUL MN
55116-1931
US

IV. Provider business mailing address

8170 33RD AVE S - PO BOX 1309 MS 21110Q
MINNEAPOLIS MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 651-265-0000
  • Fax: 651-265-0001
Mailing address:
  • Phone: 651-265-0000
  • Fax: 651-265-0001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number11262
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: