Provider Demographics
NPI:1114042074
Name:BRYAN, MARK WILLIAM (DC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:BRYAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2815 YELM HWY SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-4829
Mailing Address - Country:US
Mailing Address - Phone:360-456-8605
Mailing Address - Fax:360-456-0155
Practice Address - Street 1:2815 YELM HWY SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-4829
Practice Address - Country:US
Practice Address - Phone:360-456-8605
Practice Address - Fax:360-456-0155
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00002146111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAT02848Medicare UPIN
WA001001469Medicare ID - Type Unspecified