Healthcare Provider Details

I. General information

NPI: 1710403621
Provider Name (Legal Business Name): BRYSON EDWIN CREWS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2017
Last Update Date: 02/22/2021
Certification Date: 02/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 LAUREL ST STE 3250
DES MOINES IA
50314-3026
US

IV. Provider business mailing address

PO BOX 1475
DES MOINES IA
50305-1475
US

V. Phone/Fax

Practice location:
  • Phone: 515-643-6400
  • Fax: 515-643-5816
Mailing address:
  • Phone: 515-643-6400
  • Fax: 515-643-5816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number096160
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3399
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: