Provider Demographics
NPI:1083614127
Name:BRYAN, JOHN PHILIP (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PHILIP
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 1:323S 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-1401
Mailing Address - Country:US
Mailing Address - Phone:920-743-5566
Mailing Address - Fax:920-746-3515
Practice Address - Street 1:225 CROSSLAKE DR
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-8198
Practice Address - Country:US
Practice Address - Phone:812-477-1558
Practice Address - Fax:812-488-4669
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002612363AM0700X
IN99039830A363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI383450619OtherCOMMUNITY CHOICE BILLING
MI19788OtherPRIORITY HEALTH
MI19788OtherPRIORITY HEALTH
MIN79030001Medicare ID - Type UnspecifiedBILLING NUMBER