Basic Information
| Provider Information | |||||||||
| NPI: | 1780829168 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOSORA | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1345 RXR PLZ FL 13 | ||||||||
| Address2: | |||||||||
| City: | UNIONDALE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115561301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5164530435 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1755 N MECKLENBURG AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH HILL | ||||||||
| State: | VA | ||||||||
| PostalCode: | 239704080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4345845025 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2008 | ||||||||
| LastUpdateDate: | 08/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | LT22008 | ME | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 0102206048 | VA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | OP60864272 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.