Basic Information
| Provider Information | |||||||||
| NPI: | 1346334075 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONKLIN | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | RICHARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2011 FOURTH STREET | ||||||||
| Address2: | |||||||||
| City: | LA GRANDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419634139 | ||||||||
| FaxNumber: | 5419634412 | ||||||||
| Practice Location | |||||||||
| Address1: | 2011 FOURTH STREET | ||||||||
| Address2: | |||||||||
| City: | LA GRANDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978501200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419634139 | ||||||||
| FaxNumber: | 5419634412 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 04/19/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD23049 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 228792 | 05 | OR | MEDICAID |