Provider Demographics
NPI:1356607568
Name:DODSON, BRYAN ALLAN (PA-C)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:ALLAN
Last Name:DODSON
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 1:142 SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-3048
Mailing Address - Country:US
Mailing Address - Phone:304-255-4348
Mailing Address - Fax:
Practice Address - Street 1:1710 HARPER RD
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3357
Practice Address - Country:US
Practice Address - Phone:304-256-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-02
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1099474363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant