Healthcare Provider Details

I. General information

NPI: 1134360761
Provider Name (Legal Business Name): BRYAN T MOYNIHAN P.A.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2009
Last Update Date: 11/09/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14555 CORTEZ BLVD
BROOKSVILLE FL
34613-6003
US

IV. Provider business mailing address

5400 PINEHURST DR
SPRING HILL FL
34606-3833
US

V. Phone/Fax

Practice location:
  • Phone: 352-556-4823
  • Fax: 352-556-4824
Mailing address:
  • Phone: 352-277-5305
  • Fax: 352-616-0926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9104935
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: