Healthcare Provider Details

I. General information

NPI: 1275462889
Provider Name (Legal Business Name): BRANDON THOMAS WALKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 NORTHWYND CIR APT 24
LYNCHBURG VA
24502-2984
US

IV. Provider business mailing address

111 NORTHWYND CIR APT 24
LYNCHBURG VA
24502-2984
US

V. Phone/Fax

Practice location:
  • Phone: 804-658-6712
  • Fax:
Mailing address:
  • Phone: 804-658-6712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: