Healthcare Provider Details

I. General information

NPI: 1548740350
Provider Name (Legal Business Name): BRANDON WENGER DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2018
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4229 LAFAYETTE CENTER DR STE 1250
CHANTILLY VA
20151-1266
US

IV. Provider business mailing address

4229 LAFAYETTE CENTER DR STE 1250
CHANTILLY VA
20151-1266
US

V. Phone/Fax

Practice location:
  • Phone: 703-263-2020
  • Fax:
Mailing address:
  • Phone: 703-263-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305212295
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: