Provider Demographics
NPI:1528002904
Name:CANFIELD, BRYAN
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:CANFIELD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 W GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-2074
Mailing Address - Country:US
Mailing Address - Phone:262-268-5100
Mailing Address - Fax:262-329-2731
Practice Address - Street 1:1475 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-2074
Practice Address - Country:US
Practice Address - Phone:262-268-5100
Practice Address - Fax:262-329-2731
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4880225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1528002904Medicaid
WI40405900Medicaid