Healthcare Provider Details

I. General information

NPI: 1053503458
Provider Name (Legal Business Name): JOSH CHARLES MOULIN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2007
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 W KANSAS
GREENSBURG KS
67054
US

IV. Provider business mailing address

721 W KANSAS
GREENSBURG KS
67054
US

V. Phone/Fax

Practice location:
  • Phone: 620-723-4217
  • Fax: 620-508-2067
Mailing address:
  • Phone: 620-723-4217
  • Fax: 620-508-2067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code282NR1301X
TaxonomyRural Acute Care Hospital
License NumberT01460
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1501214
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15-01214
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: