Provider Demographics
NPI:1992202790
Name:HNATIO, BRYAN ADAM (PA-C)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:ADAM
Last Name:HNATIO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37719 MARGARETA DR
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-2611
Mailing Address - Country:US
Mailing Address - Phone:734-837-2718
Mailing Address - Fax:
Practice Address - Street 1:8623 N TELEGRAPH RD STE 1
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-1489
Practice Address - Country:US
Practice Address - Phone:313-561-4540
Practice Address - Fax:313-561-9515
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008438363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2626671Medicaid