Provider Demographics
NPI:1497814891
Name:BRYAN, JOHN R (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:BRYAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:SHIPROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87420
Mailing Address - Country:US
Mailing Address - Phone:505-368-6401
Mailing Address - Fax:505-368-6431
Practice Address - Street 1:US HWY 491 NORTH
Practice Address - Street 2:
Practice Address - City:SHIPROCK
Practice Address - State:NM
Practice Address - Zip Code:87420
Practice Address - Country:US
Practice Address - Phone:505-368-6401
Practice Address - Fax:505-368-6431
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000308A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO26126818Medicaid
NM74676512Medicaid
AZ918394Medicaid
AZ918394Medicaid
S55128Medicare UPIN
8HD386Medicare PIN