Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 253 | OK |
Y | 222Z00000X | Podiatrist | 253 | OK |
N | 213EP1101X | Primary Podiatric Medicine | 253 | OK |
N | 111NR0200X | Radiology | 253 | OK |
N | 213ER0200X | Radiology | 253 | OK |
N | 2081S0010X | Sports Medicine | 253 | OK |
N | 213ES0000X | Sports Medicine | 253 | OK |
N | 213ES0103X | Foot & Ankle Surgery | 253 | OK |
NPI | 1215906276 |
---|---|
Provider Name | Dr. Bryan Andrew Blanck |
First Address | Ada, OK 74820-4067 |
Second Address | Ada, OK 74820-4073 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/03/2006 |
Last Update Date | 28/07/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200119690A | (05) | OK |