Provider Demographics
NPI:1619917200
Name:BELNAP, BRYANT (PT)
Entity Type:Individual
Prefix:
First Name:BRYANT
Middle Name:
Last Name:BELNAP
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 1:3345 MERLIN DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7405
Mailing Address - Country:US
Mailing Address - Phone:208-522-4481
Mailing Address - Fax:208-522-6137
Practice Address - Street 1:3345 MERLIN DR
Practice Address - Street 2:SUITE 100
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7405
Practice Address - Country:US
Practice Address - Phone:208-522-4481
Practice Address - Fax:208-522-6137
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-343225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1653900Medicare ID - Type Unspecified