Provider Demographics
NPI:1609032481
Name:BRYAN, BRANDON DONALD (CRNA)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:DONALD
Last Name:BRYAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 CREEKS XING
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-1764
Mailing Address - Country:US
Mailing Address - Phone:318-294-1187
Mailing Address - Fax:
Practice Address - Street 1:401 E VAUGHN AVE
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5950
Practice Address - Country:US
Practice Address - Phone:318-294-1187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN107925 AP05353367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered