Healthcare Provider Details

I. General information

NPI: 1841944402
Provider Name (Legal Business Name): CARSON BRYAN JD, PRSS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2022
Last Update Date: 02/11/2022
Certification Date: 02/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2333 MACCORKLE AVE
SAINT ALBANS WV
25177-2073
US

IV. Provider business mailing address

2333 MACCORKLE AVE
SAINT ALBANS WV
25177-2073
US

V. Phone/Fax

Practice location:
  • Phone: 681-205-8548
  • Fax: 855-888-9316
Mailing address:
  • Phone: 681-205-8548
  • Fax: 855-888-9316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number21-971
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: