Provider Demographics
NPI:1285625921
Name:BRYANT, GEORGE BURTON JR (PAC)
Entity type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:BURTON
Last Name:BRYANT
Suffix:JR
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:208 DAWKINS DRIVE
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901
Mailing Address - Country:US
Mailing Address - Phone:304-645-7227
Mailing Address - Fax:681-318-3479
Practice Address - Street 1:9016 SENECA TRL S
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-8375
Practice Address - Country:US
Practice Address - Phone:681-318-3477
Practice Address - Fax:681-318-3479
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV172363A00000X
WV508363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVP90305Medicare UPIN