Healthcare Provider Details

I. General information

NPI: 1588548101
Provider Name (Legal Business Name): BRYAN ANTHONY SMALL CSFA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2025
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4358 BROAD STREET ROAD
GUM SPRING VA
23065
US

IV. Provider business mailing address

4358 BROAD STREET ROAD
GUM SPRING VA
23065
US

V. Phone/Fax

Practice location:
  • Phone: 540-223-3922
  • Fax:
Mailing address:
  • Phone: 540-223-3922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number0137001523
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number0136000162
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: