Provider Demographics
NPI:1063505444
Name:BRAUN, BRYAN LEE (PAC)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:LEE
Last Name:BRAUN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE DR.
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:541-524-8000
Mailing Address - Fax:541-524-7955
Practice Address - Street 1:3325 POCAHONTAS RD
Practice Address - Street 2:
Practice Address - City:BAKER CITY
Practice Address - State:OR
Practice Address - Zip Code:97814
Practice Address - Country:US
Practice Address - Phone:541-524-8000
Practice Address - Fax:541-524-7955
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00659207R00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine