Provider Demographics
NPI:1790109817
Name:BRYANT, CORY (APN ANESTHETIST)
Entity Type:Individual
Prefix:MR
First Name:CORY
Middle Name:
Last Name:BRYANT
Suffix:
Gender:M
Credentials:APN ANESTHETIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9213 ANDOVER RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19114-3818
Mailing Address - Country:US
Mailing Address - Phone:215-609-8930
Mailing Address - Fax:
Practice Address - Street 1:509 N BROAD ST
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-1617
Practice Address - Country:US
Practice Address - Phone:856-845-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-10
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00484800367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered