Provider Demographics
NPI:1083042790
Name:FILLMORE, BRYAN
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:FILLMORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9040 JACKSON AVE
Mailing Address - Street 2:MAMC-PHYSICAL THERAPY
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-5000
Mailing Address - Country:US
Mailing Address - Phone:253-968-3042
Mailing Address - Fax:
Practice Address - Street 1:9040 JACKSON AVE
Practice Address - Street 2:MAMC-PHYSICAL THERAPY
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-5000
Practice Address - Country:US
Practice Address - Phone:253-968-3042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist