Healthcare Provider Details

I. General information

NPI: 1043290026
Provider Name (Legal Business Name): RUSSELL WAYNE BRYAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 TURNER ST BRANCH HEALTH CLINIC, NAVAL AIR STATION
PENSACOLA FL
32508-5211
US

IV. Provider business mailing address

5800 W FAIRFIELD DR
PENSACOLA FL
32506-3440
US

V. Phone/Fax

Practice location:
  • Phone: 850-452-5242
  • Fax:
Mailing address:
  • Phone: 850-455-4201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110840787
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: