Provider Demographics
NPI:1700615911
Name:TANICALA, BRYSON (PT, DPT)
Entity type:Individual
Prefix:
First Name:BRYSON
Middle Name:
Last Name:TANICALA
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8363 AURORA RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-6238
Mailing Address - Country:US
Mailing Address - Phone:808-366-2710
Mailing Address - Fax:
Practice Address - Street 1:10040 ALTA DR STE 230
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89145-8630
Practice Address - Country:US
Practice Address - Phone:725-726-7847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-29
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist