Provider Demographics
NPI:1053479980
Name:BRYDON, JAN K (MD)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:K
Last Name:BRYDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 W 24TH ST STE 305
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16502-2666
Mailing Address - Country:US
Mailing Address - Phone:814-454-4484
Mailing Address - Fax:
Practice Address - Street 1:311 W 24TH ST STE 305
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16502-2666
Practice Address - Country:US
Practice Address - Phone:814-454-4484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD029742E207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA131540Medicare ID - Type Unspecified
B37665Medicare UPIN