Provider Demographics
NPI:1164920930
Name:BRYANT, CATHERINE SUPPLE (PA-C)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:SUPPLE
Last Name:BRYANT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CATHERINE
Other - Middle Name:ELLEN
Other - Last Name:SUPPLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1190 N STATE ST STE 502
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2414
Mailing Address - Country:US
Mailing Address - Phone:601-944-1781
Mailing Address - Fax:
Practice Address - Street 1:1190 N STATE ST STE 502
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2414
Practice Address - Country:US
Practice Address - Phone:601-944-1781
Practice Address - Fax:601-353-0439
Is Sole Proprietor?:No
Enumeration Date:2018-01-26
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical