Healthcare Provider Details

I. General information

NPI: 1730573379
Provider Name (Legal Business Name): BRIAN THOMAS RNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2015
Last Update Date: 03/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70542 SWINGLE RD
BRIDGEPORT OH
43912-9722
US

IV. Provider business mailing address

70542 SWINGLE RD
BRIDGEPORT OH
43912-9722
US

V. Phone/Fax

Practice location:
  • Phone: 740-635-1877
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number51357
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberRN.277273-
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: