Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PT37936 | CA |
NPI | 1003204215 |
---|---|
Provider Name | Mr. Jonathan Bryant |
First Address | Fountain Valley, CA 92708-6529 |
Second Address | Downey, CA 90242-3456 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/12/2014 |
Last Update Date | 23/12/2014 |