Provider Demographics
NPI:1114610193
Name:SERBER, BRIAN JEFFREY (PTA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JEFFREY
Last Name:SERBER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8987 UNDERWOOD LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-6730
Mailing Address - Country:US
Mailing Address - Phone:612-805-4894
Mailing Address - Fax:
Practice Address - Street 1:6200 XERXES AVE S
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55423-1033
Practice Address - Country:US
Practice Address - Phone:952-925-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-26
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA2844225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty