=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649099169
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSEPH C BRYANT JR. NP-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2024
-----------------------------------------------------
Last Update Date | 10/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1601 WATSON BLVD
-----------------------------------------------------
City | WARNER ROBINS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31093-3431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-550-5510
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3016 WESTGATE DR
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31721-2151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-255-9044
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | RN243663
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------