MEDICARE: MR. NICHOLAS JEROME BRYANT RNFA

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	363L00000X	Nurse Practitioner	AP132757	TX

General Provider Information

NPI Number	:	1902069040
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. NICHOLAS JEROME BRYANT RNFA

Provider Business Mailing Address
First Line	:	PO BOX 670039
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75367-0039
Country	:	US
Telephone Number	:	214-378-9898
Fax Number	:	214-378-9888

Provider Business Practice Location Address
First Line	:	10830 N CENTRAL EXPY
Second Line	:	SUITE 120
City	:	DALLAS
State	:	TX
Zip	:	75231-1050
Country	:	US
Telephone Number	:	214-378-9898
Fax Number	:	214-378-9888

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

Provider Enumeration Date	:	07/09/2008
Last Update Date	:	08/07/2017

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