Provider Demographics
NPI:1750666970
Name:BRYANT, KEENE WILSON (PA)
Entity Type:Individual
Prefix:MR
First Name:KEENE
Middle Name:WILSON
Last Name:BRYANT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11140 MONTGOMERY RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45249-2309
Mailing Address - Country:US
Mailing Address - Phone:513-221-5500
Mailing Address - Fax:513-221-1962
Practice Address - Street 1:11140 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45249-2309
Practice Address - Country:US
Practice Address - Phone:513-221-5500
Practice Address - Fax:513-221-1962
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003394363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0070176Medicaid
0225920002Medicare NSC
OH0070176Medicaid