Provider Demographics
NPI:1982039319
Name:CANTU, BRANDON JAMES (PTA)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:JAMES
Last Name:CANTU
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-2445
Mailing Address - Country:US
Mailing Address - Phone:719-937-2254
Mailing Address - Fax:719-937-2221
Practice Address - Street 1:1012 MAIN ST
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-2445
Practice Address - Country:US
Practice Address - Phone:719-937-2254
Practice Address - Fax:719-937-2221
Is Sole Proprietor?:No
Enumeration Date:2013-09-04
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO12533225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant