Provider Demographics
NPI:1689076861
Name:BRYAN, YAICHA (PA)
Entity Type:Individual
Prefix:
First Name:YAICHA
Middle Name:
Last Name:BRYAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HEALTH PARK DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80027-9583
Mailing Address - Country:US
Mailing Address - Phone:303-673-1000
Mailing Address - Fax:303-673-1204
Practice Address - Street 1:100 HEALTH PARK DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-9583
Practice Address - Country:US
Practice Address - Phone:303-673-1000
Practice Address - Fax:303-673-1204
Is Sole Proprietor?:No
Enumeration Date:2014-09-19
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003186363AM0700X
CO0004635363AM0700X, 363A00000X
COPA.0004635363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO531543YLTTMedicare PIN