Provider Demographics
NPI:1679788400
Name:NAGATA, BRYAN T
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:T
Last Name:NAGATA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1424 EL CAMINO DR
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-3221
Mailing Address - Country:US
Mailing Address - Phone:310-795-3891
Mailing Address - Fax:
Practice Address - Street 1:6033 W CENTURY BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-6410
Practice Address - Country:US
Practice Address - Phone:310-258-0684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT28378225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist