Provider Demographics
NPI:1477944148
Name:ROSE, BRYAN
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:ROSE
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 1:8142 S 68TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-4177
Mailing Address - Country:US
Mailing Address - Phone:918-551-6787
Mailing Address - Fax:918-551-6787
Practice Address - Street 1:8142 S 68TH EAST AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-4177
Practice Address - Country:US
Practice Address - Phone:918-551-6787
Practice Address - Fax:918-551-6787
Is Sole Proprietor?:No
Enumeration Date:2015-02-16
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200497250AMedicaid
OKOKB5377Medicare PIN