Provider Demographics
NPI:1952719205
Name:BROYAN, CHANNING
Entity type:Individual
Prefix:
First Name:CHANNING
Middle Name:
Last Name:BROYAN
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 1:1442 MILITARY CUTOFF RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-3605
Mailing Address - Country:US
Mailing Address - Phone:910-256-6088
Mailing Address - Fax:910-256-6089
Practice Address - Street 1:1442 MILITARY CUTOFF RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-3605
Practice Address - Country:US
Practice Address - Phone:910-256-6088
Practice Address - Fax:910-256-6089
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-31
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-04910363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant