Provider Demographics
NPI:1073584140
Name:BRYAN, JAMES R (PA-C)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:R
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 1:2415 MCCALLIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-3322
Mailing Address - Country:US
Mailing Address - Phone:423-624-2696
Mailing Address - Fax:423-697-2059
Practice Address - Street 1:4625 N LEE HWY
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-4042
Practice Address - Country:US
Practice Address - Phone:423-624-2696
Practice Address - Fax:423-697-2059
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00063207Q00000X
TNPA63363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNS96199Medicare UPIN
TN3668895Medicare PIN