Provider Demographics
NPI:1477532596
Name:VAN SISE, BRIAN S (MPT)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:S
Last Name:VAN SISE
Suffix:
Gender:M
Credentials:MPT
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5010 STATE HIGHWAY 30
Mailing Address - Street 2:MOHAWK VALLEY MEDICAL ARTS BUILDING
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010
Mailing Address - Country:US
Mailing Address - Phone:518-212-6291
Mailing Address - Fax:518-212-2222
Practice Address - Street 1:5010 STATE HIGHWAY 30
Practice Address - Street 2:MOHAWK VALLEY MEDICAL ARTS BUILDING
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010
Practice Address - Country:US
Practice Address - Phone:518-212-6291
Practice Address - Fax:518-212-2222
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023122225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00697301Medicaid
NY00697301Medicaid