Provider Demographics
NPI:1922061035
Name:BRYANT, VICKI (PA-C)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:
Last Name:BRYANT
Suffix:
Gender:F
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 1:365 BROOKDALE DR
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-4103
Mailing Address - Country:US
Mailing Address - Phone:704-872-3630
Mailing Address - Fax:704-872-0049
Practice Address - Street 1:365 BROOKDALE DR
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-4103
Practice Address - Country:US
Practice Address - Phone:704-872-3630
Practice Address - Fax:704-872-0049
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100062363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2752788BMedicare ID - Type Unspecified
NCP02969Medicare UPIN
970026557Medicare PIN