Provider Demographics
NPI:1992375349
Name:DAVISON, BRIAN R (PTA)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:R
Last Name:DAVISON
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 1:12202 LYNDELL PLANTATION DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32407-2620
Mailing Address - Country:US
Mailing Address - Phone:850-691-9144
Mailing Address - Fax:
Practice Address - Street 1:2211 S HIGHWAY 77 STE 200
Practice Address - Street 2:
Practice Address - City:LYNN HAVEN
Practice Address - State:FL
Practice Address - Zip Code:32444-4641
Practice Address - Country:US
Practice Address - Phone:850-252-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA30607225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant