Provider Demographics
NPI:1801379490
Name:PERALTA, BRYAN JEFFREY
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:JEFFREY
Last Name:PERALTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18415 WISSETT WAY
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-1699
Mailing Address - Country:US
Mailing Address - Phone:570-898-4682
Mailing Address - Fax:
Practice Address - Street 1:22911 JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:SMITHSBURG
Practice Address - State:MD
Practice Address - Zip Code:21783-1617
Practice Address - Country:US
Practice Address - Phone:301-824-3343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR197653363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care