Provider Demographics
NPI:1114041381
Name:BOYLAN, BRAD (ATC, PT)
Entity Type:Individual
Prefix:MR
First Name:BRAD
Middle Name:
Last Name:BOYLAN
Suffix:
Gender:M
Credentials:ATC, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 VINE ST SW
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-2545
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3705 COLUMBUS ST SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322-6182
Practice Address - Country:US
Practice Address - Phone:541-967-4522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2491225100000X
ORAT-AT-1833012255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer