Provider Demographics
NPI:1932894037
Name:MOON, BRYAN MICHAEL
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:MICHAEL
Last Name:MOON
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 1:434 WESTVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:OH
Mailing Address - Zip Code:45067-1030
Mailing Address - Country:US
Mailing Address - Phone:513-292-6042
Mailing Address - Fax:
Practice Address - Street 1:434 WESTVIEW AVE
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:OH
Practice Address - Zip Code:45067-1030
Practice Address - Country:US
Practice Address - Phone:513-292-6042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-06
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN227360172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver