Provider Demographics
NPI:1457779522
Name:VAN HOOMISSEN, BRYN
Entity Type:Individual
Prefix:
First Name:BRYN
Middle Name:
Last Name:VAN HOOMISSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 ERWIN RD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-4699
Mailing Address - Country:US
Mailing Address - Phone:919-684-8111
Mailing Address - Fax:
Practice Address - Street 1:2825 STOCKYARD RD STE I-200
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1548
Practice Address - Country:US
Practice Address - Phone:406-728-8420
Practice Address - Fax:406-541-8430
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-04
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC390200000X
MTMED-PHYS-LIC-66778207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program