Healthcare Provider Details

I. General information

NPI: 1265491237
Provider Name (Legal Business Name): JEFFRY MICHAEL BRYEN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 04/05/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 S DOUGLAS BLVD
MIDWEST CITY OK
73130-6221
US

IV. Provider business mailing address

PO BOX 113
WANETTE OK
74878-0113
US

V. Phone/Fax

Practice location:
  • Phone: 405-302-8999
  • Fax: 405-733-9360
Mailing address:
  • Phone: 405-694-6950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number699
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: