Provider Demographics
NPI:1376009944
Name:PURCELL, BRYAN WILLIAM
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:WILLIAM
Last Name:PURCELL
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 1:4 POMPER CT
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-6417
Mailing Address - Country:US
Mailing Address - Phone:917-817-3541
Mailing Address - Fax:
Practice Address - Street 1:4 POMPER CT
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-6417
Practice Address - Country:US
Practice Address - Phone:917-817-3541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY308830363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health