Provider Demographics
NPI:1598391351
Name:WANDLING, BRYSON LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:BRYSON
Middle Name:LEE
Last Name:WANDLING
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 1:3280 N 250 E
Mailing Address - Street 2:
Mailing Address - City:NORTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84414-1582
Mailing Address - Country:US
Mailing Address - Phone:801-837-0998
Mailing Address - Fax:
Practice Address - Street 1:815 E. CESAR CHAVEZ BLVD.
Practice Address - Street 2:
Practice Address - City:SAN LUIS
Practice Address - State:AZ
Practice Address - Zip Code:85349
Practice Address - Country:US
Practice Address - Phone:928-627-3822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-12
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7850363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant