Provider Demographics
NPI:1164013868
Name:MOSHER, BRADLEY
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:MOSHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4835 CLARKSTONE DR
Mailing Address - Street 2:
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-3326
Mailing Address - Country:US
Mailing Address - Phone:678-897-8408
Mailing Address - Fax:
Practice Address - Street 1:1325 SATELLITE BLVD NW BLDG 400
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-4651
Practice Address - Country:US
Practice Address - Phone:678-263-3080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN256219363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health