Provider Demographics
NPI:1982180196
Name:BRYAN, JUSTIN PATRICK (PA)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:PATRICK
Last Name:BRYAN
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 1:10 ATKINS ST APT 2
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-1602
Mailing Address - Country:US
Mailing Address - Phone:207-233-5289
Mailing Address - Fax:
Practice Address - Street 1:125 PARKER HILL AVE BLDG SUITE560
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02120-2847
Practice Address - Country:US
Practice Address - Phone:617-860-6130
Practice Address - Fax:617-860-6135
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA6265363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant