Healthcare Provider Details

I. General information

NPI: 1528065844
Provider Name (Legal Business Name): BRYON J WITZEL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 03/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD SUITE 3005B
SAINT LOUIS MO
63141-8232
US

IV. Provider business mailing address

621 S NEW BALLAS RD SUITE 3005B
SAINT LOUIS MO
63141-8232
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-7070
  • Fax: 314-251-7071
Mailing address:
  • Phone: 314-251-7070
  • Fax: 314-251-7071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2006034878
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number085-002185
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: