Provider Demographics
NPI:1598741860
Name:CANWELL, BRYAN LEE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:LEE
Last Name:CANWELL
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:P.O. BOX 160
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801
Mailing Address - Country:US
Mailing Address - Phone:541-966-9830
Mailing Address - Fax:509-826-3653
Practice Address - Street 1:46314 TIMINE WAY
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801
Practice Address - Country:US
Practice Address - Phone:541-966-9830
Practice Address - Fax:541-240-8751
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA157064363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8370884Medicaid
WA8944528OtherL&I-CRIME VICTIM
OR500650388Medicaid
OR500650388Medicaid
WA8370884Medicaid