Provider Demographics
NPI:1457835290
Name:MEYENBERG, BRYAN P (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:P
Last Name:MEYENBERG
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25554 RIVER RNCH
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78255-9548
Mailing Address - Country:US
Mailing Address - Phone:210-884-0637
Mailing Address - Fax:
Practice Address - Street 1:1450 METZGER ST BLDG 10416
Practice Address - Street 2:
Practice Address - City:LACKLAND AFB
Practice Address - State:TX
Practice Address - Zip Code:78236-5423
Practice Address - Country:US
Practice Address - Phone:210-671-7744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT20532255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer