Provider Demographics
NPI:1366725541
Name:KEARNEY, BRYANT RANDALL (PAC)
Entity type:Individual
Prefix:MR
First Name:BRYANT
Middle Name:RANDALL
Last Name:KEARNEY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:250 26TH ST
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE DU SAC
Mailing Address - State:WI
Mailing Address - Zip Code:53578-2204
Mailing Address - Country:US
Mailing Address - Phone:608-643-2471
Mailing Address - Fax:608-643-4788
Practice Address - Street 1:250 26TH ST
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU SAC
Practice Address - State:WI
Practice Address - Zip Code:53578-2204
Practice Address - Country:US
Practice Address - Phone:608-643-2471
Practice Address - Fax:608-643-4788
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2836-023363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical