Provider Demographics
NPI:1770721052
Name:ADAMS, BRYTTNIE MEAGAN (PTA)
Entity type:Individual
Prefix:
First Name:BRYTTNIE
Middle Name:MEAGAN
Last Name:ADAMS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2364 N APPLE LN
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-7231
Mailing Address - Country:US
Mailing Address - Phone:903-875-5408
Mailing Address - Fax:
Practice Address - Street 1:2364 N APPLE LN
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-7231
Practice Address - Country:US
Practice Address - Phone:903-875-5408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-26
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2064487225200000X
IDPTA-340225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant