Basic Information
Provider Information
NPI: 1003143223
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BRYNELSON
FirstName: GREGORY
MiddleName: SUMNER PAYNE
NamePrefix: MR.
NameSuffix:  
Credential: RN
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: BRYNELSON
OtherFirstName: GREG
OtherMiddleName: PAYNE
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential: RN
OtherLastNameType: 5
Mailing Information
Address1: 555 MISSION ROCK ST UNIT 103
Address2:  
City: SAN FRANCISCO
State: CA
PostalCode: 941582150
CountryCode: US
TelephoneNumber: 4155132902
FaxNumber:  
Practice Location
Address1: 555 MISSION ROCK ST UNIT 103
Address2:  
City: SAN FRANCISCO
State: CA
PostalCode: 941582150
CountryCode: US
TelephoneNumber: 4155132902
FaxNumber:  
Other Information
ProviderEnumerationDate: 11/09/2009
LastUpdateDate: 11/09/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
163WM0705X689286CAY Nursing Service ProvidersRegistered NurseMedical-Surgical

No ID Information.


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