Provider Demographics
NPI:1619097722
Name:COON, BRIAN DAVID (PT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:DAVID
Last Name:COON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 STATE ST
Mailing Address - Street 2:SUITE 16, LL
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16501-1341
Mailing Address - Country:US
Mailing Address - Phone:814-480-7100
Mailing Address - Fax:814-480-7604
Practice Address - Street 1:2101 NAGLE RD
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16510-2131
Practice Address - Country:US
Practice Address - Phone:814-877-7078
Practice Address - Fax:814-899-5484
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT007026L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA762502OtherBLUE SHIELD
PA1616794OtherAETNA
PA0015328390004Medicaid
PA1616794OtherAETNA