Basic Information
| Provider Information | |||||||||
| NPI: | 1508035270 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRYANT | ||||||||
| FirstName: | TAWANNA | ||||||||
| MiddleName: | J | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 670 | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923730221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095806210 | ||||||||
| FaxNumber: | 9095801363 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 N PEPPER AVE | ||||||||
| Address2: | DEPT.GENERAL SURGERY MOD 3 | ||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923241801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095806210 | ||||||||
| FaxNumber: | 9095801363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2008 | ||||||||
| LastUpdateDate: | 11/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA19573 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | GR0079700 | 05 | CA | MEDICAID |