Basic Information
| Provider Information | |||||||||
| NPI: | 1619939741 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRYAN | ||||||||
| FirstName: | TONYA | ||||||||
| MiddleName: | LYNNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6401 UNIVERSITY AVE NE | ||||||||
| Address2: | |||||||||
| City: | FRIDLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554324341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635725710 | ||||||||
| FaxNumber: | 7635713008 | ||||||||
| Practice Location | |||||||||
| Address1: | 13819 HANSON BLVD NW | ||||||||
| Address2: | |||||||||
| City: | ANDOVER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553047608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635725710 | ||||||||
| FaxNumber: | 7638624490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 10/06/2011 | ||||||||
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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 | 208000000X | 43377 | MN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 128387 | 01 | MN | UCARE MN | OTHER | 59G17BR | 01 | MN | BCBS OF MN | OTHER | 011648300 | 05 | MN | MEDICAID | 6605841 | 01 | MN | MEDICA UC | OTHER | HP35365 | 01 | MN | HEALTHPARTNERS | OTHER | 1030993 | 01 | MN | PREFERRED ONE | OTHER | 1201818 | 01 | MN | MEDICA | OTHER | 1594350 | 01 | MN | AMERICA'S PPO | OTHER | 7978447 | 01 | MN | AETNA | OTHER |