Provider Demographics
NPI:1306616321
Name:CERRO, BRYAN
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:CERRO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2656 N 61ST ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53213-1540
Mailing Address - Country:US
Mailing Address - Phone:608-358-7767
Mailing Address - Fax:
Practice Address - Street 1:450 30TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3302
Practice Address - Country:US
Practice Address - Phone:510-869-6511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-02
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
WI8073363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program