Provider Demographics
NPI:1073934758
Name:GHIOSSI, BRYAN (PT)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:GHIOSSI
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 1:3441 ALMA ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94306-3506
Mailing Address - Country:US
Mailing Address - Phone:650-323-4440
Mailing Address - Fax:650-323-4441
Practice Address - Street 1:FILE 50469
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90074-0469
Practice Address - Country:US
Practice Address - Phone:530-778-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-23
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40775225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA40775OtherPT LICENSE