Provider Demographics
NPI:1508542028
Name:BRYANT, DEVERIOUS DECARLOS
Entity Type:Individual
Prefix:
First Name:DEVERIOUS
Middle Name:DECARLOS
Last Name:BRYANT
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 1:8890 RANSLEY STATION BLVD
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32534-9588
Mailing Address - Country:US
Mailing Address - Phone:334-524-6480
Mailing Address - Fax:
Practice Address - Street 1:11000 UNIVERSITY PKWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-5732
Practice Address - Country:US
Practice Address - Phone:850-291-2501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program