Provider Demographics
NPI:1427300052
Name:MABRY, BRIAN ALAN (BRIAN MABRY)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:ALAN
Last Name:MABRY
Suffix:
Gender:M
Credentials:BRIAN MABRY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:POMEROY
Mailing Address - State:WA
Mailing Address - Zip Code:99347-9705
Mailing Address - Country:US
Mailing Address - Phone:509-843-1591
Mailing Address - Fax:509-843-1234
Practice Address - Street 1:66 N 6TH ST
Practice Address - Street 2:
Practice Address - City:POMEROY
Practice Address - State:WA
Practice Address - Zip Code:99347-9705
Practice Address - Country:US
Practice Address - Phone:509-843-1591
Practice Address - Fax:509-843-1234
Is Sole Proprietor?:No
Enumeration Date:2012-10-05
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003623363AM0700X
WAPA60564965363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH20358733200OtherBWC GROUP
OH2630700Medicaid
OH20358733200OtherBWC GROUP