MEDICARE: MR. BRYSON HOUSTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program		PA

General Provider Information

NPI Number	:	1992549158
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRYSON HOUSTON

Provider Business Mailing Address
First Line	:	1242 POINT BREEZE AVE APT 203
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19146-4363
Country	:	US
Telephone Number	:	972-768-9855
Fax Number	:

Provider Business Practice Location Address
First Line	:	1242 POINT BREEZE AVE APT 203
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19146-4363
Country	:	US
Telephone Number	:	972-768-9855
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2024
Last Update Date	:	06/22/2024

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