=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649915380
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRYAN ALONZO GIRALDO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2022
-----------------------------------------------------
Last Update Date | 04/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13915 BURNET RD STE 204
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78728-6537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-583-3792
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20200 BOGGY FORD RD
-----------------------------------------------------
City | LAGO VISTA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78645-2009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-586-5189
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 2168756
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------