Provider Demographics
NPI:1922062231
Name:CUSTER, BRYAN G (PA-C)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:G
Last Name:CUSTER
Suffix:
Gender:M
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 1:1800 E PARK AVE
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16803-6701
Mailing Address - Country:US
Mailing Address - Phone:814-234-6110
Mailing Address - Fax:814-234-6765
Practice Address - Street 1:1800 E PARK AVE
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-6701
Practice Address - Country:US
Practice Address - Phone:814-234-6110
Practice Address - Fax:814-234-6765
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051396363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
087352Medicare ID - Type Unspecified
P40724Medicare UPIN