Provider Demographics
NPI:1841602661
Name:BRINSON, DWAYNE (ISSA CERTIFICATION)
Entity Type:Individual
Prefix:MR
First Name:DWAYNE
Middle Name:
Last Name:BRINSON
Suffix:
Gender:M
Credentials:ISSA CERTIFICATION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6789 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-5907
Mailing Address - Country:US
Mailing Address - Phone:716-632-1742
Mailing Address - Fax:
Practice Address - Street 1:6789 MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-5907
Practice Address - Country:US
Practice Address - Phone:716-632-1742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-28
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4302922255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer