Healthcare Provider Details

I. General information

NPI: 1073648614
Provider Name (Legal Business Name): PAUL H BRYANT PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 12/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CHERRY ST SE
GRAND RAPIDS MI
49503-4526
US

IV. Provider business mailing address

550 CHERRY ST SE
GRAND RAPIDS MI
49503-4748
US

V. Phone/Fax

Practice location:
  • Phone: 616-235-7272
  • Fax:
Mailing address:
  • Phone: 616-735-7272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601002233
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: