Provider Demographics
NPI:1174646087
Name:BRYANT, MARK ANTHONY (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:BRYANT
Suffix:
Gender:M
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:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:WHITLEY CITY
Mailing Address - State:KY
Mailing Address - Zip Code:42653-0099
Mailing Address - Country:US
Mailing Address - Phone:606-376-5391
Mailing Address - Fax:
Practice Address - Street 1:19 MEDICAL LOOP
Practice Address - Street 2:SUITE 3
Practice Address - City:WHITLEY CITY
Practice Address - State:KY
Practice Address - Zip Code:42653
Practice Address - Country:US
Practice Address - Phone:606-376-5391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA958363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant