Provider Demographics
NPI:1346989563
Name:LORD, BRYCE THOMAS
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:THOMAS
Last Name:LORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7000 CHAD COLLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72916-6024
Mailing Address - Country:US
Mailing Address - Phone:479-308-2243
Mailing Address - Fax:479-431-5387
Practice Address - Street 1:7000 CHAD COLLEY BLVD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72916-6024
Practice Address - Country:US
Practice Address - Phone:479-308-2243
Practice Address - Fax:478-431-5387
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-04
Last Update Date:2022-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA602AH0340390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1082722960OtherTRICARE