Provider Demographics
NPI:1962727487
Name:BRYAN, KERRI (PA)
Entity type:Individual
Prefix:
First Name:KERRI
Middle Name:
Last Name:BRYAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 SPLENDOR CIR
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-7086
Mailing Address - Country:US
Mailing Address - Phone:912-508-2502
Mailing Address - Fax:
Practice Address - Street 1:8229 SHOAL CREEK BLVD STE 105
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-7556
Practice Address - Country:US
Practice Address - Phone:737-738-5046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-29
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X, 363A00000X
SCTL1550363AM0700X
MDC0004149363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1111PAMedicaid
SCAA60286672Medicare PIN