Provider Demographics
NPI:1407354202
Name:JOW, BRYAN (MPAS, DMSC)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:JOW
Suffix:
Gender:M
Credentials:MPAS, DMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 ANDREWS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT NOVOSEL
Mailing Address - State:AL
Mailing Address - Zip Code:36362
Mailing Address - Country:US
Mailing Address - Phone:334-255-7449
Mailing Address - Fax:
Practice Address - Street 1:301 ANDREWS AVE.
Practice Address - Street 2:
Practice Address - City:FORT NOVOSEL
Practice Address - State:AL
Practice Address - Zip Code:36362
Practice Address - Country:US
Practice Address - Phone:334-255-7449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-26
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1149096OtherNCCPA ID