Healthcare Provider Details

I. General information

NPI: 1750050035
Provider Name (Legal Business Name): ROSS PATRICK BRANTNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2021
Last Update Date: 09/09/2021
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4350 E ELMWOOD ST
TUCSON AZ
85711-2959
US

IV. Provider business mailing address

4350 E ELMWOOD ST
TUCSON AZ
85711-2959
US

V. Phone/Fax

Practice location:
  • Phone: 520-312-1067
  • Fax:
Mailing address:
  • Phone: 152-031-2106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5757
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: