Provider Demographics
NPI:1316028129
Name:WHITESIDES, BRYAN PAUL (MPT, OCS)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:PAUL
Last Name:WHITESIDES
Suffix:
Gender:M
Credentials:MPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 25 1/2 RD
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81505-6401
Mailing Address - Country:US
Mailing Address - Phone:970-242-3535
Mailing Address - Fax:978-068-3274
Practice Address - Street 1:627 25 1/2 RD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-6401
Practice Address - Country:US
Practice Address - Phone:970-242-3535
Practice Address - Fax:978-068-3274
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0006022225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO8803Medicare ID - Type Unspecified