1598741860 NPI number — MR. BRYAN LEE CANWELL PA-C

Table of content: MR. BRYAN LEE CANWELL PA-C (NPI 1598741860)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598741860 NPI number — MR. BRYAN LEE CANWELL PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CANWELL
Provider First Name:
BRYAN
Provider Middle Name:
LEE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598741860
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 160
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENDLETON
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-966-9830
Provider Business Mailing Address Fax Number:
509-826-3653

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
46314 TIMINE WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENDLETON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-966-9830
Provider Business Practice Location Address Fax Number:
541-240-8751
Provider Enumeration Date:
12/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA157064 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8370884 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8944528 . This is a "L&I-CRIME VICTIM" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 500650388 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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