Provider Demographics
NPI:1255421954
Name:SOUTHARDS, BRYN MAYBERRY (PA-C)
Entity type:Individual
Prefix:MRS
First Name:BRYN
Middle Name:MAYBERRY
Last Name:SOUTHARDS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:BRYN
Other - Middle Name:LEANN
Other - Last Name:MAYBERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:608 NORRIS AVE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37204-3708
Mailing Address - Country:US
Mailing Address - Phone:615-695-1432
Mailing Address - Fax:615-695-1483
Practice Address - Street 1:8 CITY BLVD STE 300
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37209-2560
Practice Address - Country:US
Practice Address - Phone:615-329-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA1436363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3664962Medicare PIN