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NPI Code Detail

MEDICARE: THERESA BRYANT PA

MEDICARE: THERESA BRYANT PA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician AssistantPA08105TX

General Provider Information

NPI Number : 1205173424
Entity Type Code : Individual
Provider Name (Legal Business Name) : THERESA BRYANT PA
Provider Business Mailing Address
First Line : 5750 W VICKERY BLVD STE 104
Second Line :
City : FORT WORTH
State : TX
Zip : 76107-7448
Country : US
Telephone Number : 817-732-2878
Fax Number : 817-737-9315
Provider Business Practice Location Address
First Line : 5750 W VICKERY BLVD STE 104
Second Line :
City : FORT WORTH
State : TX
Zip : 76107-7448
Country : US
Telephone Number : 817-732-2878
Fax Number : 817-737-9315
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/08/2013
Last Update Date : 07/17/2019

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Directions to “ THERESA BRYANT PA” Practice Location

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