Provider Demographics
NPI:1245534296
Name:KETTNER, BRIAN ROBERT (PT)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:ROBERT
Last Name:KETTNER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8302 ESPRESSO DR
Mailing Address - Street 2:100
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93312-5687
Mailing Address - Country:US
Mailing Address - Phone:661-377-1700
Mailing Address - Fax:661-616-9199
Practice Address - Street 1:2960 E NEES AVE
Practice Address - Street 2:108
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-6012
Practice Address - Country:US
Practice Address - Phone:559-322-4103
Practice Address - Fax:661-616-9199
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-05
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT37421225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist