Healthcare Provider Details

I. General information

NPI: 1396832416
Provider Name (Legal Business Name): KIMBERLY ANN MOSELEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2006
Last Update Date: 02/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 SAINT MICHAELS DR
SANTA FE NM
87505-7601
US

IV. Provider business mailing address

455 SAINT MICHAELS DR
SANTA FE NM
87505-7601
US

V. Phone/Fax

Practice location:
  • Phone: 505-913-3975
  • Fax:
Mailing address:
  • Phone: 505-913-3975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD38996
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberE-5272
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD2011-0065
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: