Provider Demographics
NPI:1356600043
Name:HAWKER, BRANDON SCOTT (DPT)
Entity type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:SCOTT
Last Name:HAWKER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 W FRANCIS ST
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1751
Mailing Address - Country:US
Mailing Address - Phone:208-785-0123
Mailing Address - Fax:208-782-1885
Practice Address - Street 1:285 W FRANCIS ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1751
Practice Address - Country:US
Practice Address - Phone:208-785-0123
Practice Address - Fax:208-782-1885
Is Sole Proprietor?:No
Enumeration Date:2012-05-15
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT2977225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805694300Medicaid
IDT9453OtherBLUE CROSS
IDT9453OtherBLUE CROSS