Provider Demographics
NPI:1851446561
Name:HUNTSMAN, BRYAN D (MS, PT)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:D
Last Name:HUNTSMAN
Suffix:
Gender:M
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2570 CHANNING WAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7515
Mailing Address - Country:US
Mailing Address - Phone:208-529-8005
Mailing Address - Fax:208-529-0251
Practice Address - Street 1:2570 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7515
Practice Address - Country:US
Practice Address - Phone:208-529-8005
Practice Address - Fax:208-529-0251
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-457174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID004401200Medicaid
ID000010025914OtherBLUE SHIELD OF IDAHO ID#
ID82-0510764OtherTAX ID#
IDT-144-3OtherBLUE CROSS OF IDAHO ID#
IDT-144-3OtherBLUE CROSS OF IDAHO ID#