Healthcare Provider Details

I. General information

NPI: 1912930009
Provider Name (Legal Business Name): BRIAN EDWARD WYSONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2290 REMOUNT RD
GASTONIA NC
28054-4725
US

IV. Provider business mailing address

2550 COURT DR STE 201
GASTONIA NC
28054-2152
US

V. Phone/Fax

Practice location:
  • Phone: 704-867-1402
  • Fax: 888-720-2814
Mailing address:
  • Phone: 704-867-1402
  • Fax: 704-671-2661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2006-00934
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: