Healthcare Provider Details

I. General information

NPI: 1255711495
Provider Name (Legal Business Name): CHRIS DYSART DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2015
Last Update Date: 10/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1827 HICKORY AVE STE B
HARAHAN LA
70123
US

IV. Provider business mailing address

1827 HICKORY AVE STE B
HARAHAN LA
70123-5613
US

V. Phone/Fax

Practice location:
  • Phone: 504-360-2584
  • Fax: 504-360-2084
Mailing address:
  • Phone: 504-360-2584
  • Fax: 504-360-2084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number09077R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: