Provider Demographics
NPI:1609173962
Name:BRISCO, BARRY LEE (CNIM, REEG T)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:LEE
Last Name:BRISCO
Suffix:
Gender:M
Credentials:CNIM, REEG T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1547 TARRYTOWN ST
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-3821
Mailing Address - Country:US
Mailing Address - Phone:650-346-6342
Mailing Address - Fax:
Practice Address - Street 1:450 STANYAN ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117-1019
Practice Address - Country:US
Practice Address - Phone:800-305-6234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-23
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
1126OtherR.EEG T.
2099OtherCNIM