Healthcare Provider Details

I. General information

NPI: 1811015134
Provider Name (Legal Business Name): BRIAN ISON PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1756 W 100 S
PORTLAND IN
47371-8204
US

IV. Provider business mailing address

3813 S MADISON ST
MUNCIE IN
47302-5758
US

V. Phone/Fax

Practice location:
  • Phone: 260-726-4020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06002259A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: