Provider Demographics
NPI:1134360761
Name:MOYNIHAN, BRYAN T (PAC)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:T
Last Name:MOYNIHAN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 PINEHURST DR
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34606-3833
Mailing Address - Country:US
Mailing Address - Phone:352-277-5305
Mailing Address - Fax:352-616-0926
Practice Address - Street 1:14555 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-6003
Practice Address - Country:US
Practice Address - Phone:352-556-4823
Practice Address - Fax:352-556-4824
Is Sole Proprietor?:No
Enumeration Date:2009-03-11
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104935363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001348200Medicaid
FLP01366463OtherRAILROAD MEDICARE
FLBR388ZMedicare PIN