Healthcare Provider Details

I. General information

NPI: 1275168429
Provider Name (Legal Business Name): BRANDON ANTHONY HANCZ PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2020
Last Update Date: 03/09/2020
Certification Date: 03/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 S 7TH ST
WILLIAMS AZ
86046-2324
US

IV. Provider business mailing address

3465 E BETSY LN
GILBERT AZ
85296-7333
US

V. Phone/Fax

Practice location:
  • Phone: 928-635-4441
  • Fax:
Mailing address:
  • Phone: 310-435-1601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number13749A
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: