Healthcare Provider Details

I. General information

NPI: 1619939741
Provider Name (Legal Business Name): TONYA LYNNE BRYAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 10/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13819 HANSON BLVD NW
ANDOVER MN
55304-7608
US

IV. Provider business mailing address

6401 UNIVERSITY AVE NE
FRIDLEY MN
55432-4341
US

V. Phone/Fax

Practice location:
  • Phone: 763-572-5710
  • Fax: 763-862-4490
Mailing address:
  • Phone: 763-572-5710
  • Fax: 763-571-3008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number43377
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: