Provider Demographics
NPI:1912407289
Name:BRISCOE, CRAIG WILLIAM (PTA)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:WILLIAM
Last Name:BRISCOE
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 1:6830 W 121ST CT
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66209-2021
Mailing Address - Country:US
Mailing Address - Phone:913-239-8777
Mailing Address - Fax:
Practice Address - Street 1:8505 PFLUMM RD
Practice Address - Street 2:
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66215-2468
Practice Address - Country:US
Practice Address - Phone:913-825-9927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-13
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-02162225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant