Provider Demographics
NPI:1689924839
Name:BRYAN, TIMOTHY A SR (PA)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:A
Last Name:BRYAN
Suffix:SR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5665 NEW NORTHSIDE DR NW
Mailing Address - Street 2:SUITE 320
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5831
Mailing Address - Country:US
Mailing Address - Phone:770-874-6844
Mailing Address - Fax:
Practice Address - Street 1:5665 NEW NORTHSIDE DR NW
Practice Address - Street 2:SUITE 320
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-5831
Practice Address - Country:US
Practice Address - Phone:770-874-6844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-14
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2994-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100043936Medicaid