Provider Demographics
NPI:1851042683
Name:WYROSDIC, BRIANNA NICOLE
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:NICOLE
Last Name:WYROSDIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 BEACON RD
Mailing Address - Street 2:
Mailing Address - City:HULL
Mailing Address - State:MA
Mailing Address - Zip Code:02045-1403
Mailing Address - Country:US
Mailing Address - Phone:781-635-0098
Mailing Address - Fax:
Practice Address - Street 1:3261 W STATE RD
Practice Address - Street 2:
Practice Address - City:SAINT BONAVENTURE
Practice Address - State:NY
Practice Address - Zip Code:14778-9800
Practice Address - Country:US
Practice Address - Phone:781-635-0098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-13
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA9440363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA000000000Medicaid