Provider Demographics
NPI:1750753810
Name:WALLACE, BRANDON (DPT, PTA)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DPT, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4003 BLOCK DR APT 1112
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-8010
Mailing Address - Country:US
Mailing Address - Phone:903-436-1880
Mailing Address - Fax:504-349-6844
Practice Address - Street 1:250 US-377
Practice Address - Street 2:SUITE 300
Practice Address - City:ARGYLE
Practice Address - State:TX
Practice Address - Zip Code:76226
Practice Address - Country:US
Practice Address - Phone:940-489-1460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-28
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA9272225200000X
TX2146592225200000X
TX13807042251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant