Healthcare Provider Details

I. General information

NPI: 1730801754
Provider Name (Legal Business Name): CLAY DEAN BRYANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2022
Last Update Date: 09/15/2022
Certification Date: 08/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 E VAUGHN AVE
RUSTON LA
71270-5950
US

IV. Provider business mailing address

176 HIGHWAY 148
RUSTON LA
71270-8436
US

V. Phone/Fax

Practice location:
  • Phone: 318-254-2100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number227362
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: