Healthcare Provider Details

I. General information

NPI: 1851743942
Provider Name (Legal Business Name): EMILY JEANNE BRYL PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2016
Last Update Date: 04/30/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5120 MASTHEAD ST NE
ALBUQUERQUE NM
87109-4366
US

IV. Provider business mailing address

5120 MASTHEAD ST NE
ALBUQUERQUE NM
87109-4366
US

V. Phone/Fax

Practice location:
  • Phone: 505-243-7546
  • Fax: 505-243-7547
Mailing address:
  • Phone: 505-243-7546
  • Fax: 505-243-7547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberPA20160066
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: