Provider Demographics
NPI:1225014897
Name:MCCOY, BRYAN LEE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:LEE
Last Name:MCCOY
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 1:805 N KELSO AVE
Mailing Address - Street 2:
Mailing Address - City:KELSO
Mailing Address - State:WA
Mailing Address - Zip Code:98626-4230
Mailing Address - Country:US
Mailing Address - Phone:360-425-2115
Mailing Address - Fax:
Practice Address - Street 1:1711 DOOLITTLE AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76127-1133
Practice Address - Country:US
Practice Address - Phone:817-782-5913
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02987363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical