Healthcare Provider Details

I. General information

NPI: 1871946814
Provider Name (Legal Business Name): BRANDON BISHOP PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2016
Last Update Date: 07/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 REVOLUTIONARY BLVD
DOVER DE
19901-8871
US

IV. Provider business mailing address

120 REVOLUTIONARY BLVD
DOVER DE
19901-8871
US

V. Phone/Fax

Practice location:
  • Phone: 443-207-0355
  • Fax:
Mailing address:
  • Phone: 443-207-0355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberJ2-0001067
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: