Provider Demographics
NPI:1235778499
Name:HISAKA, BRENT RYO (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:RYO
Last Name:HISAKA
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4421 WEEPING SPRUCE CT
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94521-4442
Mailing Address - Country:US
Mailing Address - Phone:925-348-7783
Mailing Address - Fax:
Practice Address - Street 1:744 52ND ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-1810
Practice Address - Country:US
Practice Address - Phone:510-428-3558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-04
Last Update Date:2020-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT297227225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist