Provider Demographics
NPI:1225669690
Name:MOSELY, BRANDON LEE (AG-ACNP)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:LEE
Last Name:MOSELY
Suffix:
Gender:M
Credentials:AG-ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3535 PENTAGON BLVD
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-1705
Mailing Address - Country:US
Mailing Address - Phone:937-702-4450
Mailing Address - Fax:937-702-4459
Practice Address - Street 1:5297 GRANTLAND DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429-2126
Practice Address - Country:US
Practice Address - Phone:937-570-2292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-03
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.388552163WC0200X
OHAPRN.CNP026716363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine