Provider Demographics
NPI:1194851444
Name:MAGNA, BRIAN ALBERT SR (PT)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:ALBERT
Last Name:MAGNA
Suffix:SR
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 1:302 W. MAIN STREET
Mailing Address - Street 2:SUITE 152
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001
Mailing Address - Country:US
Mailing Address - Phone:860-679-0430
Mailing Address - Fax:860-679-0431
Practice Address - Street 1:302 W. MAIN STREET
Practice Address - Street 2:SUITE 152
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001
Practice Address - Country:US
Practice Address - Phone:860-679-0430
Practice Address - Fax:860-679-0431
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004285261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy