Healthcare Provider Details

I. General information

NPI: 1598741860
Provider Name (Legal Business Name): BRYAN LEE CANWELL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 08/12/2020
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46314 TIMINE WAY
PENDLETON OR
97801
US

IV. Provider business mailing address

P.O. BOX 160
PENDLETON OR
97801
US

V. Phone/Fax

Practice location:
  • Phone: 541-966-9830
  • Fax: 541-240-8751
Mailing address:
  • Phone: 541-966-9830
  • Fax: 509-826-3653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA157064
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: