Provider Demographics
NPI:1639739022
Name:LAWSON, BRYAN PHILIP (PT)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:PHILIP
Last Name:LAWSON
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 1:920 DEON DR
Mailing Address - Street 2:STE D
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-425-1470
Mailing Address - Fax:108-425-1471
Practice Address - Street 1:920 DEON DR
Practice Address - Street 2:STE D
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-425-1470
Practice Address - Fax:108-425-1471
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-18
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-6198208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation