Provider Demographics
NPI:1689390973
Name:TA, BRIAN (PT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:TA
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 1:1215 SE 8TH AVE STE D
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-3497
Mailing Address - Country:US
Mailing Address - Phone:503-248-0360
Mailing Address - Fax:503-200-1148
Practice Address - Street 1:1215 SE 8TH AVE STE D
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-3497
Practice Address - Country:US
Practice Address - Phone:503-248-0360
Practice Address - Fax:503-200-1148
Is Sole Proprietor?:No
Enumeration Date:2022-10-18
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR639512251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORC392786OtherOREGON DRIVERS LICENSE