Provider Demographics
NPI:1962884114
Name:FLYNN, BRYAN KEITH
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:KEITH
Last Name:FLYNN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3851 HARRISON RD
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72019-9632
Mailing Address - Country:US
Mailing Address - Phone:501-607-0144
Mailing Address - Fax:501-794-1021
Practice Address - Street 1:3851 HARRISON RD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72019-9632
Practice Address - Country:US
Practice Address - Phone:501-607-0144
Practice Address - Fax:501-794-1021
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-24
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROPP00053222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist