Provider Demographics
NPI:1912485574
Name:BRYCE WILLARDSON, LLC
Entity type:Organization
Organization Name:BRYCE WILLARDSON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:801-824-4334
Mailing Address - Street 1:83960 SPRING HILL LN
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:OR
Mailing Address - Zip Code:97455-9728
Mailing Address - Country:US
Mailing Address - Phone:801-824-4334
Mailing Address - Fax:
Practice Address - Street 1:83960 SPRING HILL LN
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:OR
Practice Address - Zip Code:97455-9728
Practice Address - Country:US
Practice Address - Phone:801-824-4334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-04
Last Update Date:2018-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201404741207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR5006740Medicaid