Healthcare Provider Details

I. General information

NPI: 1780499616
Provider Name (Legal Business Name): BRIAN SHARP PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2025
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14775 N KIMO CT STE A
RATHDRUM ID
83858-8762
US

IV. Provider business mailing address

850 W IRONWOOD DR STE 202
COEUR D ALENE ID
83814-4903
US

V. Phone/Fax

Practice location:
  • Phone: 208-687-9240
  • Fax: 208-687-9241
Mailing address:
  • Phone: 208-664-2175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number61624607
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: