Provider Demographics
NPI:1518977826
Name:HART, BRYAN G (PA)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:G
Last Name:HART
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:1072 N LIBERTY ST
Practice Address - Street 2:SUITE 303
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-2800
Practice Address - Country:US
Practice Address - Phone:208-367-4035
Practice Address - Fax:208-367-7111
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA397363A00000X
IDPA-397363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPAWF2OtherBLUE CROSS OF IDAHO
OR134024OtherOMAP
ID000010139458OtherREGENCE BLUE SHIELD
ID8J703OtherBLUE CROSS OF IDAHO GROUP
ID8J190OtherBLUE CROSS OF IDAHO GROUP
WA0209674OtherWA DEPARTMENT OF LABOR
IDPAOV4OtherBLUE CROSS OF IDAHO
IDPAWF2OtherBLUE CROSS OF IDAHO
P83515Medicare UPIN
16678201Medicare PIN
1667828Medicare PIN
ID8J703OtherBLUE CROSS OF IDAHO GROUP
ID8J190OtherBLUE CROSS OF IDAHO GROUP