Provider Demographics
NPI:1780149948
Name:TIPTON, BRYAN KENNETH (PA-C, MPAS)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:KENNETH
Last Name:TIPTON
Suffix:
Gender:M
Credentials:PA-C, MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 AVENUE H
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:WY
Mailing Address - Zip Code:82435-2260
Mailing Address - Country:US
Mailing Address - Phone:307-754-2267
Mailing Address - Fax:307-754-7257
Practice Address - Street 1:777 AVENUE H
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:WY
Practice Address - Zip Code:82435-2260
Practice Address - Country:US
Practice Address - Phone:307-754-7257
Practice Address - Fax:307-754-7217
Is Sole Proprietor?:No
Enumeration Date:2019-02-01
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPA827363A00000X
WYPT827363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical