Healthcare Provider Details

I. General information

NPI: 1902069040
Provider Name (Legal Business Name): NICHOLAS JEROME BRYANT RNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 08/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10830 N CENTRAL EXPY SUITE 120
DALLAS TX
75231-1050
US

IV. Provider business mailing address

PO BOX 670039
DALLAS TX
75367-0039
US

V. Phone/Fax

Practice location:
  • Phone: 214-378-9898
  • Fax: 214-378-9888
Mailing address:
  • Phone: 214-378-9898
  • Fax: 214-378-9888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP132757
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: