Provider Demographics
NPI:1851331003
Name:BRYANT, ROGER CARL (CRNA)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:CARL
Last Name:BRYANT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 2527
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75606-2527
Mailing Address - Country:US
Mailing Address - Phone:903-655-1313
Mailing Address - Fax:903-657-6067
Practice Address - Street 1:906 JUDSON RD
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5113
Practice Address - Country:US
Practice Address - Phone:903-655-1313
Practice Address - Fax:903-657-6067
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX46399367500000X
TX604469367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX169620501Medicaid
TXS17197Medicare UPIN
S17197Medicare UPIN
TX8C8331Medicare PIN