Healthcare Provider Details

I. General information

NPI: 1750666970
Provider Name (Legal Business Name): KEENE WILSON BRYANT P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2011
Last Update Date: 06/01/2022
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11140 MONTGOMERY RD
CINCINNATI OH
45249-2309
US

IV. Provider business mailing address

11140 MONTGOMERY RD
CINCINNATI OH
45249-2309
US

V. Phone/Fax

Practice location:
  • Phone: 513-221-5500
  • Fax: 513-221-1962
Mailing address:
  • Phone: 513-221-5500
  • Fax: 513-221-1962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.003394
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: