Provider Demographics
NPI:1346223401
Name:O'NEALL, BRYAN T (PA)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:T
Last Name:O'NEALL
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 1:4515 MARSHA SHARP FWY
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79407-2520
Mailing Address - Country:US
Mailing Address - Phone:806-744-7223
Mailing Address - Fax:806-740-3325
Practice Address - Street 1:4515 MARSHA SHARP FWY
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79407-2520
Practice Address - Country:US
Practice Address - Phone:806-744-7223
Practice Address - Fax:806-740-3325
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX PA 02717363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7271774OtherAETNA - GRACE CLINIC
TX8AM633OtherBCBS - GRACE CLINIC
TX8L3991OtherMEDICARE PIN - GRACE CLINIC
TX161309100OtherFIRSTCARE - GRACE CLINIC
TX5892790001OtherMEDICARE NSC - GRACE CLINIC
TX161309100OtherTEAM CHOICE CORE - GRACE CLINIC
TX1975187-01Medicaid
TX8AM633OtherBCBS - GRACE CLINIC
TX1975187-01Medicaid