Provider Demographics
NPI:1225552664
Name:TIPTON, BROGAN (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:BROGAN
Middle Name:
Last Name:TIPTON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:DR
Other - First Name:BROGAN
Other - Middle Name:
Other - Last Name:UPHOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:20336 SCHOLAR LN
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65583-3418
Mailing Address - Country:US
Mailing Address - Phone:217-855-7745
Mailing Address - Fax:
Practice Address - Street 1:24530 SOUTHSIDE RD
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583-3317
Practice Address - Country:US
Practice Address - Phone:217-855-7745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-27
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021048123225100000X
KY007181225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist