Provider Demographics
NPI:1710959697
Name:BRYAN, JAIMIE L (PA C)
Entity Type:Individual
Prefix:
First Name:JAIMIE
Middle Name:L
Last Name:BRYAN
Suffix:
Gender:F
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 1:8220 US 19 NORTH
Mailing Address - Street 2:
Mailing Address - City:PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34668
Mailing Address - Country:US
Mailing Address - Phone:727-841-8505
Mailing Address - Fax:727-846-0561
Practice Address - Street 1:8220 US 19 NORTH
Practice Address - Street 2:
Practice Address - City:PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34668
Practice Address - Country:US
Practice Address - Phone:727-841-8505
Practice Address - Fax:727-846-0561
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102529207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q09408Medicare UPIN
FLU2102WMedicare ID - Type Unspecified