Provider Demographics
NPI:1073530598
Name:BRYANT, GEORGE (ANP)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:
Last Name:BRYANT
Suffix:
Gender:M
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:C B 8056
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-747-1171
Mailing Address - Fax:314-747-8254
Practice Address - Street 1:4921 PARKVIEW PL
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-747-1171
Practice Address - Fax:314-747-8254
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005019124363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
S72255Medicare UPIN