Provider Demographics
NPI:1861128142
Name:BILBAO, BRYAN MARCEL (PA-C)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:MARCEL
Last Name:BILBAO
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 1:187 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLD FORGE
Mailing Address - State:PA
Mailing Address - Zip Code:18518-1755
Mailing Address - Country:US
Mailing Address - Phone:570-589-9375
Mailing Address - Fax:
Practice Address - Street 1:575 N RIVER ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-2634
Practice Address - Country:US
Practice Address - Phone:570-829-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-28
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA390200000X
PA1202111363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program