Provider Demographics
NPI:1629497649
Name:KIRK, BRYAN EDWARD (PMH-NP)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:EDWARD
Last Name:KIRK
Suffix:
Gender:M
Credentials:PMH-NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9632
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-9562
Mailing Address - Country:US
Mailing Address - Phone:940-322-5477
Mailing Address - Fax:940-720-0018
Practice Address - Street 1:1708 DAYTON AVE
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-6110
Practice Address - Country:US
Practice Address - Phone:940-322-5477
Practice Address - Fax:940-720-0018
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-08
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP124702363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX353600502Medicaid
TX397149ZRW5Medicare PIN