MEDICARE: MS. KATHYANN CYNTHELESE BRYANT LSA

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
1	225700000X	Massage Therapist	MT034925	TX
2	246ZC0007X	Surgical Assistant	SA00606	TX
3	363AS0400X	Surgical Physician Assistant

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00P07U	OTHER	TX	BCBS - OLTON SURGICAL SERVICES, LLC
2	SA00606	OTHER	TX	TEXAS MEDICAL BOARD

General Provider Information

NPI Number	:	1285871053
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KATHYANN CYNTHELESE BRYANT LSA

Provider Business Mailing Address
First Line	:	PO BOX 541602
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77254-1602
Country	:	US
Telephone Number	:	832-428-7532
Fax Number	:	832-602-2638

Provider Business Practice Location Address
First Line	:	10133 IRVINGTON BLVD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77076-4412
Country	:	US
Telephone Number	:	832-428-7532
Fax Number	:	832-602-2638

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/14/2009
Last Update Date	:	10/13/2020

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