Provider Demographics
NPI:1093265753
Name:BRYAN, MARY BAILEY WICKHAM (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARY BAILEY
Middle Name:WICKHAM
Last Name:BRYAN
Suffix:
Gender:F
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 1:112 N 12TH ST UNIT 1208
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-3745
Mailing Address - Country:US
Mailing Address - Phone:706-566-3556
Mailing Address - Fax:
Practice Address - Street 1:2300 MANCHESTER EXPY STE 101A
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904
Practice Address - Country:US
Practice Address - Phone:706-322-6646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-06
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109944363A00000X
GA008723363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9109944Medicaid