Provider Demographics
NPI:1508035270
Name:BRYANT, TAWANNA J
Entity Type:Individual
Prefix:
First Name:TAWANNA
Middle Name:J
Last Name:BRYANT
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:PO BOX 670
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-0221
Mailing Address - Country:US
Mailing Address - Phone:909-580-6210
Mailing Address - Fax:909-580-1363
Practice Address - Street 1:400 N PEPPER AVE
Practice Address - Street 2:DEPT.GENERAL SURGERY MOD 3
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-1801
Practice Address - Country:US
Practice Address - Phone:909-580-6210
Practice Address - Fax:909-580-1363
Is Sole Proprietor?:No
Enumeration Date:2008-02-26
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19573363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0079700Medicaid
CAGR0079700Medicaid