Provider Demographics
NPI:1417362252
Name:BRYAN, KERI
Entity Type:Individual
Prefix:
First Name:KERI
Middle Name:
Last Name:BRYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 SHILOH RD STE C110
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-1406
Mailing Address - Country:US
Mailing Address - Phone:903-939-2800
Mailing Address - Fax:
Practice Address - Street 1:921 SHILOH RD STE C110
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1406
Practice Address - Country:US
Practice Address - Phone:903-939-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-30
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4053120225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant