Provider Demographics
NPI:1801370945
Name:HARR, BRYAN DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:DAVID
Last Name:HARR
Suffix:
Gender:M
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 1:5123 N BLACK SAND AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-6261
Mailing Address - Country:US
Mailing Address - Phone:334-538-3266
Mailing Address - Fax:
Practice Address - Street 1:1675 E RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6237
Practice Address - Country:US
Practice Address - Phone:208-900-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1634363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty