Healthcare Provider Details

I. General information

NPI: 1366781213
Provider Name (Legal Business Name): KARLY MARIE KINCAID MOSS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2013
Last Update Date: 09/28/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3850 PLEASANT HILL RD
DULUTH GA
30096-4807
US

IV. Provider business mailing address

1180 RESURGENCE DR STE 100
WATKINSVILLE GA
30677-7211
US

V. Phone/Fax

Practice location:
  • Phone: 770-814-8222
  • Fax: 678-205-5111
Mailing address:
  • Phone: 706-543-5858
  • Fax: 706-543-2050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number006687
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: