Provider Demographics
NPI:1235464587
Name:BRYNILDSEN, MICHAEL R (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:BRYNILDSEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 GARDENVILLE PKWY W
Mailing Address - Street 2:C/O CREDENTIALING DEPARTMENT
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-1324
Mailing Address - Country:US
Mailing Address - Phone:716-857-6150
Mailing Address - Fax:716-656-4074
Practice Address - Street 1:899 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1109
Practice Address - Country:US
Practice Address - Phone:716-878-2700
Practice Address - Fax:716-878-2701
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013601363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant