Provider Demographics
NPI:1265614390
Name:BRYANT, KIESA NICHOL (PA)
Entity type:Individual
Prefix:
First Name:KIESA
Middle Name:NICHOL
Last Name:BRYANT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6725
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-0725
Mailing Address - Country:US
Mailing Address - Phone:410-721-0311
Mailing Address - Fax:443-607-1041
Practice Address - Street 1:2772 RUTLAND RD
Practice Address - Street 2:
Practice Address - City:DAVIDSONVILLE
Practice Address - State:MD
Practice Address - Zip Code:21035-1228
Practice Address - Country:US
Practice Address - Phone:410-721-0311
Practice Address - Fax:443-607-1041
Is Sole Proprietor?:No
Enumeration Date:2007-11-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002692363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant