Healthcare Provider Details

I. General information

NPI: 1669602835
Provider Name (Legal Business Name): JOSEPH J. MOISAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2009
Last Update Date: 09/03/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 LAKE AVE N DEPARTMENT OF NEUROSURGERY
WORCESTER MA
01655-0002
US

IV. Provider business mailing address

PO BOX 415348
BOSTON MA
02241-5348
US

V. Phone/Fax

Practice location:
  • Phone: 508-334-0605
  • Fax: 508-334-5074
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA3806
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00508
License Number StateRI
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA3806
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierJM84255
Identifier TypeMEDICAID
Identifier StateRI
Identifier Issuer
# 2
Identifier001697301
Identifier TypeOTHER
Identifier StateRI
Identifier IssuerMEDICARE PTAN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: