Provider Demographics
NPI:1538246491
Name:O'BRYAN, JOHN L (PA-C)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:O'BRYAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-434-3455
Mailing Address - Fax:321-434-3456
Practice Address - Street 1:1350 HICKORY ST
Practice Address - Street 2:SUITE 102
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3224
Practice Address - Country:US
Practice Address - Phone:321-434-3455
Practice Address - Fax:321-434-3456
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103993363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292613000Medicaid
FLLE023OtherFL MEDICARE
FLPA9103993OtherLICENSE
FLPA9103993OtherLICENSE