Basic Information
| Provider Information | |||||||||
| NPI: | 1740787332 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRYAN | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | RENEE' | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1967 | ||||||||
| Address2: | |||||||||
| City: | EVANS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 308091967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7069228274 | ||||||||
| FaxNumber: | 7069226695 | ||||||||
| Practice Location | |||||||||
| Address1: | 131 RINEHART WAY | ||||||||
| Address2: | |||||||||
| City: | AIKEN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 298031703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033352200 | ||||||||
| FaxNumber: | 8036497966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2018 | ||||||||
| LastUpdateDate: | 10/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 83726 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.