Provider Demographics
NPI:1093888380
Name:POE, BRYAN STANDLEY (DO)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:STANDLEY
Last Name:POE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6405 S 3000 E STE 300
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6977
Mailing Address - Country:US
Mailing Address - Phone:801-266-3113
Mailing Address - Fax:
Practice Address - Street 1:406 S PARK AVE
Practice Address - Street 2:
Practice Address - City:AZTEC
Practice Address - State:NM
Practice Address - Zip Code:87410
Practice Address - Country:US
Practice Address - Phone:505-334-2852
Practice Address - Fax:505-334-9266
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA83486207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM40931Medicaid
NM40931Medicaid
NM400521168Medicare ID - Type Unspecified