Provider Demographics
NPI:1154369973
Name:BARBOZA, BRYAN JAMES (PA)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:JAMES
Last Name:BARBOZA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 745431
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-5431
Mailing Address - Country:US
Mailing Address - Phone:843-449-5360
Mailing Address - Fax:706-653-4711
Practice Address - Street 1:2525 COURT DR
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2140
Practice Address - Country:US
Practice Address - Phone:704-834-2000
Practice Address - Fax:706-653-4711
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC104210363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2763750Medicare ID - Type Unspecified
Q47021Medicare UPIN