Healthcare Provider Details

I. General information

NPI: 1588626774
Provider Name (Legal Business Name): JOHNNY WAYNE BRYANT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 06/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

423 SOUTH 28TH ST SUITE A
PADUCAH KY
42003-3865
US

IV. Provider business mailing address

423 SOUTH 28TH ST SUITE A
PADUCAH KY
42003-3865
US

V. Phone/Fax

Practice location:
  • Phone: 270-442-7181
  • Fax: 271-442-0113
Mailing address:
  • Phone: 270-442-7181
  • Fax: 271-442-0113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number35692
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: