Provider Demographics
NPI:1861733693
Name:BRYAN, SUZANNE MARIE
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:MARIE
Last Name:BRYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3125 NORTHERTON CT
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-1793
Mailing Address - Country:US
Mailing Address - Phone:937-264-3220
Mailing Address - Fax:
Practice Address - Street 1:3125 NORTHERTON CT
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-1793
Practice Address - Country:US
Practice Address - Phone:937-264-3220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-04
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH88601292471R0002X
FL41342471R0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471R0002XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiation Therapy