Provider Demographics
NPI:1265491237
Name:BRYEN, JEFFRY MICHAEL (PA)
Entity Type:Individual
Prefix:
First Name:JEFFRY
Middle Name:MICHAEL
Last Name:BRYEN
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:PO BOX 113
Mailing Address - Street 2:
Mailing Address - City:WANETTE
Mailing Address - State:OK
Mailing Address - Zip Code:74878-0113
Mailing Address - Country:US
Mailing Address - Phone:405-694-6950
Mailing Address - Fax:
Practice Address - Street 1:1701 S DOUGLAS BLVD
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-6221
Practice Address - Country:US
Practice Address - Phone:405-302-8999
Practice Address - Fax:405-733-9360
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK699363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100113870AMedicaid
OKR83311Medicare UPIN
OK244527902Medicare ID - Type Unspecified