Provider Demographics
NPI:1285715771
Name:BRYAN, MARY IRENE (PA)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:IRENE
Last Name:BRYAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 GOLDEN RIDGE RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80401-9541
Mailing Address - Country:US
Mailing Address - Phone:303-233-1223
Mailing Address - Fax:303-233-8755
Practice Address - Street 1:660 GOLDEN RIDGE RD
Practice Address - Street 2:SUITE 250
Practice Address - City:GOLDEN
Practice Address - State:CO
Practice Address - Zip Code:80401-9541
Practice Address - Country:US
Practice Address - Phone:303-233-1223
Practice Address - Fax:303-233-8755
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA 2308363A00000X
CO2308363AM0700X
HIAMD-329363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO2308OtherLICENSE
HIA00133OtherSTATE NARC
HIAMD-329OtherHI LIC.
HIMB1491719OtherDEA
HIAMD-329OtherHI LIC.
HIMB1491719OtherDEA
COP00394783Medicare PIN