Provider Demographics
NPI:1619162799
Name:PHERSON, BRYAN LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:LEE
Last Name:PHERSON
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 1:230 E MARYDALE AVE
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7648
Mailing Address - Country:US
Mailing Address - Phone:907-262-3119
Mailing Address - Fax:907-262-9290
Practice Address - Street 1:230 E MARYDALE AVE
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7648
Practice Address - Country:US
Practice Address - Phone:907-262-3119
Practice Address - Fax:907-262-9290
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK774363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MP1638711OtherDEA
AKK161320Medicare PIN
AK0361450001Medicare NSC