Provider Demographics
NPI:1033213699
Name:BRISCOE, DAVID A (PT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:BRISCOE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 GOFF MOUNTAIN RD
Mailing Address - Street 2:SUITE 13
Mailing Address - City:CROSS LANES
Mailing Address - State:WV
Mailing Address - Zip Code:25313-6602
Mailing Address - Country:US
Mailing Address - Phone:304-776-5031
Mailing Address - Fax:304-204-6332
Practice Address - Street 1:314 GOFF MOUNTAIN RD
Practice Address - Street 2:SUITE 13
Practice Address - City:CROSS LANES
Practice Address - State:WV
Practice Address - Zip Code:25313-6602
Practice Address - Country:US
Practice Address - Phone:304-776-5031
Practice Address - Fax:304-204-6332
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002137225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001721594OtherMOUNTIAN STATE BC/BS
WV7301063000Medicaid
WV4052263Medicare PIN