Provider Demographics
NPI:1992168223
Name:BRYSON, EZRON
Entity type:Individual
Prefix:
First Name:EZRON
Middle Name:
Last Name:BRYSON
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 1:2035 TIMOTHY RD
Mailing Address - Street 2:F208
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-3285
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2035 TIMOTHY RD
Practice Address - Street 2:F208
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-3285
Practice Address - Country:US
Practice Address - Phone:706-542-2758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-04
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0027972255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer