Provider Demographics
NPI:1508424821
Name:BOSHART, BRYAN ALEX (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:ALEX
Last Name:BOSHART
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 1:3501 YUCCA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76111-4840
Mailing Address - Country:US
Mailing Address - Phone:832-922-5094
Mailing Address - Fax:
Practice Address - Street 1:3501 YUCCA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76111-4840
Practice Address - Country:US
Practice Address - Phone:832-922-5094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-01
Last Update Date:2019-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13157152251P0200X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics