Provider Demographics
NPI:1790122802
Name:BOECKMAN, BRADON THOMAS (PTA, ATC/L)
Entity Type:Individual
Prefix:MR
First Name:BRADON
Middle Name:THOMAS
Last Name:BOECKMAN
Suffix:
Gender:M
Credentials:PTA, ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10052 CONOVER RD
Mailing Address - Street 2:
Mailing Address - City:VERSAILLES
Mailing Address - State:OH
Mailing Address - Zip Code:45380-8490
Mailing Address - Country:US
Mailing Address - Phone:937-638-0783
Mailing Address - Fax:
Practice Address - Street 1:1111 SWEITZER ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:OH
Practice Address - Zip Code:45331-1189
Practice Address - Country:US
Practice Address - Phone:937-638-0783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-30
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT.0038242255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer