Provider Demographics
NPI:1053136366
Name:BOAZ, BREANNA G (PTA)
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:G
Last Name:BOAZ
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 1:478 N FORK RD
Mailing Address - Street 2:
Mailing Address - City:BLACK MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:28711-8762
Mailing Address - Country:US
Mailing Address - Phone:828-279-8279
Mailing Address - Fax:
Practice Address - Street 1:200 TABERNACLE RD
Practice Address - Street 2:
Practice Address - City:BLACK MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28711-7733
Practice Address - Country:US
Practice Address - Phone:828-357-3611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-21
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA7984225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant