Basic Information
| Provider Information | |||||||||
| NPI: | 1265446629 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KISHBAUGH | ||||||||
| FirstName: | BRANDON | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 722 MOUNT PLEASANT RD | ||||||||
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| City: | BLOOMSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178157246 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 109 W 9TH ST | ||||||||
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| City: | BERWICK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 186033024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5707590389 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT013514 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.