Provider Demographics
NPI:1487356556
Name:ENSIGN, BRYSON RICHARD (DO)
Entity type:Individual
Prefix:
First Name:BRYSON
Middle Name:RICHARD
Last Name:ENSIGN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:537 W 1420 N APT 102
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-7035
Mailing Address - Country:US
Mailing Address - Phone:801-891-3861
Mailing Address - Fax:
Practice Address - Street 1:900 MAIN ST STE 720
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-5027
Practice Address - Country:US
Practice Address - Phone:801-891-3861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program