Healthcare Provider Details

I. General information

NPI: 1427458876
Provider Name (Legal Business Name): BRANDON WAYNE HALL ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2014
Last Update Date: 09/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102C EAST AREA LOCKER ROOM THE PENNSYLVANIA STATE UNIVERSITY
UNIVERSITY PARK PA
16802
US

IV. Provider business mailing address

114 KENLEY CT
STATE COLLEGE PA
16803-1171
US

V. Phone/Fax

Practice location:
  • Phone: 814-865-8296
  • Fax:
Mailing address:
  • Phone: 814-386-1770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT004545
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: