Provider Demographics
NPI:1710281035
Name:BRYAN-LEDWELL, DANIEL JUSTIN (PA-C)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:JUSTIN
Last Name:BRYAN-LEDWELL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:DANIEL
Other - Middle Name:JUSTIN
Other - Last Name:BRYAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:900 OLD WINSTON RD
Mailing Address - Street 2:SUITE 116
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-9965
Mailing Address - Country:US
Mailing Address - Phone:336-992-0491
Mailing Address - Fax:336-450-1722
Practice Address - Street 1:900 OLD WINSTON RD
Practice Address - Street 2:SUITE 116
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-9965
Practice Address - Country:US
Practice Address - Phone:336-992-0491
Practice Address - Fax:336-450-1722
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-29
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-02688363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8102835Medicaid
NCNCB432AMedicare PIN