Healthcare Provider Details

I. General information

NPI: 1306830336
Provider Name (Legal Business Name): INAYAT M MOOSA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 07/20/2021
Certification Date: 07/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39000 BOB HOPE DR HARRY & DIANE RINKER BUILDING
RANCHO MIRAGE CA
92270-3221
US

IV. Provider business mailing address

PO BOX 1730
RANCHO MIRAGE CA
92270-1058
US

V. Phone/Fax

Practice location:
  • Phone: 760-568-2684
  • Fax: 760-837-2269
Mailing address:
  • Phone: 760-568-2684
  • Fax: 760-341-5832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA20145
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA20145
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: