Provider Demographics
NPI:1801264775
Name:BRYAN E KIRK, LLC
Entity type:Organization
Organization Name:BRYAN E KIRK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:PMH-NP
Authorized Official - Phone:940-631-7066
Mailing Address - Street 1:PO BOX 9632
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-9562
Mailing Address - Country:US
Mailing Address - Phone:940-322-5477
Mailing Address - Fax:940-720-0018
Practice Address - Street 1:1708 DAYTON AVE
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-6110
Practice Address - Country:US
Practice Address - Phone:940-322-5477
Practice Address - Fax:940-720-0018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-09
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX679387363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX356827101Medicaid
TX356827101Medicaid