Provider Demographics
NPI:1992549158
Name:HOUSTON, BRYSON
Entity type:Individual
Prefix:MR
First Name:BRYSON
Middle Name:
Last Name:HOUSTON
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 1:1242 POINT BREEZE AVE APT 203
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-4363
Mailing Address - Country:US
Mailing Address - Phone:972-768-9855
Mailing Address - Fax:
Practice Address - Street 1:1242 POINT BREEZE AVE APT 203
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146-4363
Practice Address - Country:US
Practice Address - Phone:972-768-9855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-22
Last Update Date:2024-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program