Provider Demographics
NPI:1922518232
Name:TISON, BRYAN MARSHALL (PNP-PC)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:MARSHALL
Last Name:TISON
Suffix:
Gender:M
Credentials:PNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 E 15TH ST STE 400A
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-6673
Mailing Address - Country:US
Mailing Address - Phone:405-341-1697
Mailing Address - Fax:405-341-2672
Practice Address - Street 1:2000 E 15TH ST STE 400A
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-6673
Practice Address - Country:US
Practice Address - Phone:405-341-1697
Practice Address - Fax:405-341-2672
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101670363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics