Provider Demographics
NPI:1881322196
Name:BRYANT, BENNETT WILLIS (PA)
Entity type:Individual
Prefix:
First Name:BENNETT
Middle Name:WILLIS
Last Name:BRYANT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ALLISON
Other - Middle Name:BENNETT
Other - Last Name:WILLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2285 IRIS ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80215-1657
Mailing Address - Country:US
Mailing Address - Phone:828-230-9618
Mailing Address - Fax:
Practice Address - Street 1:660 BANNOCK ST # L
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-4506
Practice Address - Country:US
Practice Address - Phone:202-436-6000
Practice Address - Fax:303-602-8505
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-13
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0007210363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant