Basic Information
Provider Information | |||||||||
NPI: | 1518906676 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRYANT | ||||||||
FirstName: | MARVIN | ||||||||
MiddleName: | LAMAR | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BRYANT | ||||||||
OtherFirstName: | M. | ||||||||
OtherMiddleName: | LAMAR | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: | JR. | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 700 NE 87TH AVE | ||||||||
Address2: |   | ||||||||
City: | VANCOUVER | ||||||||
State: | WA | ||||||||
PostalCode: | 986641913 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3608822778 | ||||||||
FaxNumber: | 3606041737 | ||||||||
Practice Location | |||||||||
Address1: | 2525 NE 139TH ST | ||||||||
Address2: |   | ||||||||
City: | VANCOUVER | ||||||||
State: | WA | ||||||||
PostalCode: | 986862719 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3608822778 | ||||||||
FaxNumber: | 3606041737 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/05/2006 | ||||||||
LastUpdateDate: | 07/21/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | MD00044491 | WA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 8431322 | 05 | WA |   | MEDICAID |