Healthcare Provider Details

I. General information

NPI: 1639762701
Provider Name (Legal Business Name): BRYAN WOODWARD PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2021
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

269 UNION ST
LYNN MA
01901-1314
US

IV. Provider business mailing address

73 BUFFUM ST
LYNN MA
01902-3965
US

V. Phone/Fax

Practice location:
  • Phone: 781-581-3900
  • Fax:
Mailing address:
  • Phone: 781-691-9486
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA8514
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: