Provider Demographics
NPI:1154081677
Name:GAITANIS, BRYAN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:GAITANIS
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19137 E KINGBIRD DR
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-5329
Mailing Address - Country:US
Mailing Address - Phone:770-256-2775
Mailing Address - Fax:
Practice Address - Street 1:19137 E KINGBIRD DR
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-5329
Practice Address - Country:US
Practice Address - Phone:770-256-2775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-23
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ223457363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care