Provider Demographics
NPI:1538314737
Name:PHANEUF, BRIAN (PTA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:PHANEUF
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3915 GOLDEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4249
Mailing Address - Country:US
Mailing Address - Phone:763-520-0579
Mailing Address - Fax:
Practice Address - Street 1:3915 GOLDEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55422-4249
Practice Address - Country:US
Practice Address - Phone:763-520-0579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-01
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA776225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant