Provider Demographics
NPI:1033652938
Name:KERNER, BRYAN ADAM (DO)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:ADAM
Last Name:KERNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 CEDAR STREET
Mailing Address - Street 2:TMP-3, #303
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3218
Mailing Address - Country:US
Mailing Address - Phone:203-737-5828
Mailing Address - Fax:
Practice Address - Street 1:330 CEDAR STREET
Practice Address - Street 2:TMP-3, #303
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3218
Practice Address - Country:US
Practice Address - Phone:203-737-5828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-23
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT66571207L00000X
WAOP60959342207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1033652938Medicaid