MEDICARE: CHARLES HARRELSON MOSS III CRNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	1-104360	AL

General Provider Information

NPI Number	:	1841447406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES HARRELSON MOSS III CRNP

Provider Business Mailing Address
First Line	:	4440 FRUITVILLE RD
Second Line	:
City	:	SARASOTA
State	:	FL
Zip	:	34232-1926
Country	:	US
Telephone Number	:	941-366-0134
Fax Number	:	941-404-1760

Provider Business Practice Location Address
First Line	:	1825 HURLBURT RD STE 14
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-3737
Country	:	US
Telephone Number	:	850-610-8820
Fax Number	:	844-297-8690

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2008
Last Update Date	:	06/25/2019

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