Provider Demographics
NPI:1851712178
Name:STILWELL, BRYSON LEE (PA)
Entity Type:Individual
Prefix:
First Name:BRYSON
Middle Name:LEE
Last Name:STILWELL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1695 KERNERSVILLE MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-7159
Mailing Address - Country:US
Mailing Address - Phone:336-515-5000
Mailing Address - Fax:
Practice Address - Street 1:1695 KERNERSVILLE MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-7159
Practice Address - Country:US
Practice Address - Phone:336-515-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-06
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0010-04765OtherNC LICENSE