Provider Demographics
NPI:1134409956
Name:PRINCE, BRYAN GLEN
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:GLEN
Last Name:PRINCE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BLDG 301 ANDREWS AVE
Mailing Address - Street 2:LYSTER ARMY HEALTH CLINIC
Mailing Address - City:FT. RUCKER
Mailing Address - State:AL
Mailing Address - Zip Code:36362-5333
Mailing Address - Country:US
Mailing Address - Phone:334-255-7000
Mailing Address - Fax:
Practice Address - Street 1:BLDG 301 ANDREWS AVE
Practice Address - Street 2:LYSTER ARMY HEALTH CLINIC
Practice Address - City:FT. RUCKER
Practice Address - State:AL
Practice Address - Zip Code:36362-5333
Practice Address - Country:US
Practice Address - Phone:334-255-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXB1901448146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic