Basic Information
Provider Information | |||||||||
NPI: | 1699767335 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BROCKETT | ||||||||
FirstName: | BRYAN | ||||||||
MiddleName: | JAMES | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 325 HANSON ST | ||||||||
Address2: |   | ||||||||
City: | WINNEMUCCA | ||||||||
State: | NV | ||||||||
PostalCode: | 894453607 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7756252222 | ||||||||
FaxNumber: | 7756251131 | ||||||||
Practice Location | |||||||||
Address1: | 5546 S FORT APACHE RD STE 200 | ||||||||
Address2: |   | ||||||||
City: | LAS VEGAS | ||||||||
State: | NV | ||||||||
PostalCode: | 891487692 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7029479994 | ||||||||
FaxNumber: | 7029479998 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/18/2005 | ||||||||
LastUpdateDate: | 04/18/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1590 | NV | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | NV1590 | 01 | NV | BCBS | OTHER | 100503507 | 05 | NV |   | MEDICAID |