Healthcare Provider Details

I. General information

NPI: 1932591963
Provider Name (Legal Business Name): BRYCE CAMPBELL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2015
Last Update Date: 04/22/2020
Certification Date: 04/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1253 NW CANAL BLVD
REDMOND OR
97756-1334
US

IV. Provider business mailing address

PO BOX 6096
BEND OR
97708-6096
US

V. Phone/Fax

Practice location:
  • Phone: 541-548-8131
  • Fax: 541-460-4028
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3350
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA179272
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: