Provider Demographics
NPI:1376652289
Name:SPRUILL, BRYAN (PA)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:SPRUILL
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 1:5002 COWHORN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-9766
Mailing Address - Country:US
Mailing Address - Phone:903-614-3008
Mailing Address - Fax:903-614-3525
Practice Address - Street 1:5002 COWHORN CREEK RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-9766
Practice Address - Country:US
Practice Address - Phone:903-614-3008
Practice Address - Fax:903-614-3525
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00599363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N3469OtherBLUESHILED
TX847N26OtherBLUE CROSS BLUE SHIELD
TX847N26OtherBLUE CROSS BLUE SHIELD
TXTXB126382Medicare PIN