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General NPI Number Information
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NPI Number | 1043290026
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Entity Type | Individual
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Provider Name | RUSSELL WAYNE BRYAN PA-C
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Gender | Male
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Dates
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Enumeration Date | 01/18/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 450 TURNER ST BRANCH HEALTH CLINIC, NAVAL AIR STATION
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City | PENSACOLA
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State | FL
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Zip | 32508-5211
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Country | US
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Telephone | 850-452-5242
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Fax |
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Provider Business Mailing Address
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Address Line | 5800 W FAIRFIELD DR
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City | PENSACOLA
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State | FL
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Zip | 32506-3440
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Country | US
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Telephone | 850-455-4201
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 0110840787
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License Number State | VA
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