Provider Demographics
NPI:1265915391
Name:WHEELER, BRYAN DYLAN (PA-C)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:DYLAN
Last Name:WHEELER
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:USA MEDDAC 11050 MOUNT BELVEDERE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602
Mailing Address - Country:US
Mailing Address - Phone:315-955-3977
Mailing Address - Fax:
Practice Address - Street 1:US ARMY
Practice Address - Street 2:CTMC
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13603
Practice Address - Country:US
Practice Address - Phone:315-955-3977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-14
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1265915391363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant