Healthcare Provider Details

I. General information

NPI: 1437232659
Provider Name (Legal Business Name): ALEX C MOSS PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 WASHINGTON ST
MONTPELIER ID
83254-1544
US

IV. Provider business mailing address

465 WASHINGTON ST
MONTPELIER ID
83254-1544
US

V. Phone/Fax

Practice location:
  • Phone: 208-847-2878
  • Fax: 208-847-2340
Mailing address:
  • Phone: 208-847-2878
  • Fax: 208-847-2340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA516
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: