Healthcare Provider Details

I. General information

NPI: 1962486829
Provider Name (Legal Business Name): CHARLES JOSEPH MOSS III CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 01/29/2020
Certification Date: 01/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 N WEBER ST
COLORADO SPRINGS CO
80903-1091
US

IV. Provider business mailing address

2 S CASCADE AVE STE 140
COLORADO SPRINGS CO
80903-1604
US

V. Phone/Fax

Practice location:
  • Phone: 719-473-6115
  • Fax: 719-472-2577
Mailing address:
  • Phone: 719-866-6568
  • Fax: 719-538-2999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number21451
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA0841
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPN.0992028-CRNA
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: