Provider Demographics
NPI:1114161080
Name:PAUL, BRYAN GEORGE
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:GEORGE
Last Name:PAUL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 NEALY AVENUE
Mailing Address - Street 2:1ST MEDICAL GROUP
Mailing Address - City:LANGLEY AFB
Mailing Address - State:VA
Mailing Address - Zip Code:23665-2040
Mailing Address - Country:US
Mailing Address - Phone:757-764-3842
Mailing Address - Fax:
Practice Address - Street 1:77 NEALY AVENUE
Practice Address - Street 2:1ST MEDICAL GROUP
Practice Address - City:LANGLEY AFB
Practice Address - State:VA
Practice Address - Zip Code:23665-2040
Practice Address - Country:US
Practice Address - Phone:757-764-3842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians