Basic Information
| Provider Information | |||||||||
| NPI: | 1619097722 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COON | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 717 STATE ST | ||||||||
| Address2: | SUITE 16, LL | ||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165011341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144807100 | ||||||||
| FaxNumber: | 8144807604 | ||||||||
| Practice Location | |||||||||
| Address1: | 2101 NAGLE RD | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165102131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148777078 | ||||||||
| FaxNumber: | 8148995484 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2007 | ||||||||
| LastUpdateDate: | 05/06/2008 | ||||||||
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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 | PT007026L | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 762502 | 01 | PA | BLUE SHIELD | OTHER | 1616794 | 01 | PA | AETNA | OTHER | 0015328390004 | 05 | PA | MEDICAID |