Provider Demographics
NPI:1043290026
Name:BRYAN, RUSSELL WAYNE (PA-C)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:WAYNE
Last Name:BRYAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5800 W FAIRFIELD DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32506-3440
Mailing Address - Country:US
Mailing Address - Phone:850-455-4201
Mailing Address - Fax:
Practice Address - Street 1:450 TURNER ST
Practice Address - Street 2:BRANCH HEALTH CLINIC, NAVAL AIR STATION
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32508-5211
Practice Address - Country:US
Practice Address - Phone:850-452-5242
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840787363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical