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General NPI Number Information
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NPI Number | 1225014897
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Entity Type | Individual
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Provider Name | BRYAN LEE MCCOY PA-C
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Gender | Male
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Dates
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Enumeration Date | 12/15/2005
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1711 DOOLITTLE AVE
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City | FORT WORTH
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State | TX
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Zip | 76127-1133
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Country | US
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Telephone | 817-782-5913
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Fax |
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Provider Business Mailing Address
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Address Line | 805 N KELSO AVE
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City | KELSO
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State | WA
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Zip | 98626-4230
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Country | US
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Telephone | 360-425-2115
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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 | PA02987
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License Number State | TX
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