Provider Demographics
NPI:1306819735
Name:BRYAN, JUANITA E (PAC)
Entity Type:Individual
Prefix:
First Name:JUANITA
Middle Name:E
Last Name:BRYAN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-479-3513
Mailing Address - Fax:260-479-3520
Practice Address - Street 1:125 E CHERRY ST
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:IN
Practice Address - Zip Code:46714
Practice Address - Country:US
Practice Address - Phone:260-824-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000231A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN370640OMedicare ID - Type Unspecified
IN911660OMedicare ID - Type Unspecified
INR86315Medicare UPIN
IN371310OMedicare ID - Type Unspecified
IN234760RMedicare PIN