1770950875 NPI number — MR. BRYAN MIZNER PA-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770950875 NPI number — MR. BRYAN MIZNER PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIZNER
Provider First Name:
BRYAN
Provider Middle Name:
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:
1770950875
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/20/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
720 N WEBB RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND ISLAND
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68803-3310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-384-2500
Provider Business Mailing Address Fax Number:
308-384-2565

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3203 OSBORNE DR W STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HASTINGS
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68901-9122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-834-1005
Provider Business Practice Location Address Fax Number:
402-303-1022
Provider Enumeration Date:
08/25/2015

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: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 079794 . This is a "PHYSICIAN ASSISTANT LICENSE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 1770950875 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 420680355-12 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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