Healthcare Provider Details

I. General information

NPI: 1164970364
Provider Name (Legal Business Name): BRYAN JOHN GOSS ACNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2016
Last Update Date: 11/20/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12303 DEPAUL DR
BRIDGETON MO
63044-2512
US

IV. Provider business mailing address

12303 DEPAUL DR
BRIDGETON MO
63044-2512
US

V. Phone/Fax

Practice location:
  • Phone: 314-344-6000
  • Fax:
Mailing address:
  • Phone: 314-344-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SE0003X
TaxonomyEmergency Clinical Nurse Specialist
License Number107699
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number107699
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number107699
License Number StateWV
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9374626
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2025039856
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: