Provider Demographics
NPI:1790135457
Name:BRAY, DYLAN (AA)
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:
Last Name:BRAY
Suffix:
Gender:M
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2135 N LAKE DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-1334
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225 S EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4257
Practice Address - Country:US
Practice Address - Phone:608-770-0908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-14
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI82-17367H00000X
COANT.0000131367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant