Provider Demographics
NPI:1699767335
Name:BROCKETT, BRYAN JAMES (PT)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:JAMES
Last Name:BROCKETT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:325 HANSON ST
Mailing Address - Street 2:
Mailing Address - City:WINNEMUCCA
Mailing Address - State:NV
Mailing Address - Zip Code:89445-3607
Mailing Address - Country:US
Mailing Address - Phone:775-625-2222
Mailing Address - Fax:775-625-1131
Practice Address - Street 1:5546 S FORT APACHE RD STE 200
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-7692
Practice Address - Country:US
Practice Address - Phone:702-947-9994
Practice Address - Fax:702-947-9998
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1590225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVNV1590OtherBCBS
NV100503507Medicaid
NV100503507Medicaid