Provider Demographics
NPI:1396036414
Name:PAYNE, BRYAN CHESLEY (PA)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:CHESLEY
Last Name:PAYNE
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 1:10 LISA CT
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-4994
Mailing Address - Country:US
Mailing Address - Phone:404-693-4655
Mailing Address - Fax:
Practice Address - Street 1:1968 PEACHTREE RD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1281
Practice Address - Country:US
Practice Address - Phone:678-216-0771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-23
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6266367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant