Provider Demographics
NPI:1295050565
Name:PAYNE, BRYAN KEITH (MD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:KEITH
Last Name:PAYNE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1599 J ST
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS AFB
Mailing Address - State:ND
Mailing Address - Zip Code:58205-6332
Mailing Address - Country:US
Mailing Address - Phone:701-747-5547
Mailing Address - Fax:
Practice Address - Street 1:1599 J ST
Practice Address - Street 2:
Practice Address - City:GRAND FORKS AFB
Practice Address - State:ND
Practice Address - Zip Code:58205-6306
Practice Address - Country:US
Practice Address - Phone:701-747-5547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-30
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ75922084P0804X, 2084P0804X
OH098454208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program