Basic Information
| Provider Information | |||||||||
| NPI: | 1083614127 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRYAN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | PHILIP | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 323S 18TH AVE | ||||||||
| Address2: | |||||||||
| City: | STURGEON BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542351401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207435566 | ||||||||
| FaxNumber: | 9207463515 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 CROSSLAKE DR | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477158198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124771558 | ||||||||
| FaxNumber: | 8124884669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 08/24/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 5601002612 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | 99039830A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 383450619 | 01 | MI | COMMUNITY CHOICE BILLING | OTHER | 19788 | 01 | MI | PRIORITY HEALTH | OTHER |