Healthcare Provider Details

I. General information

NPI: 1093888380
Provider Name (Legal Business Name): BRYAN STANDLEY POE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 02/05/2024
Certification Date: 02/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 S PARK AVE
AZTEC NM
87410
US

IV. Provider business mailing address

6405 S 3000 E STE 300
SALT LAKE CITY UT
84121-6977
US

V. Phone/Fax

Practice location:
  • Phone: 505-334-2852
  • Fax: 505-334-9266
Mailing address:
  • Phone: 801-266-3113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA83486
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: