Provider Demographics
NPI:1205173424
Name:BRYANT, THERESA (PA)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
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 1:5750 W VICKERY BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-7448
Mailing Address - Country:US
Mailing Address - Phone:817-732-2878
Mailing Address - Fax:817-737-9315
Practice Address - Street 1:5750 W VICKERY BLVD STE 104
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-7448
Practice Address - Country:US
Practice Address - Phone:817-732-2878
Practice Address - Fax:817-737-9315
Is Sole Proprietor?:No
Enumeration Date:2013-01-08
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08105363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX274358YKQLMedicare PIN
TX274358YKP5Medicare PIN
TX274358YKPWMedicare PIN