Provider Demographics
NPI:1851083075
Name:BRYAN, ETHAN RICHARD I (LPN)
Entity Type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:RICHARD
Last Name:BRYAN
Suffix:I
Gender:M
Credentials:LPN
Other - Prefix:MR
Other - First Name:ETHAN
Other - Middle Name:RICHARD
Other - Last Name:BRYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:14 LOVERS LN
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-4081
Mailing Address - Country:US
Mailing Address - Phone:631-312-3744
Mailing Address - Fax:
Practice Address - Street 1:14 LOVERS LN
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-4081
Practice Address - Country:US
Practice Address - Phone:631-312-3744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY331262164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse