Healthcare Provider Details

I. General information

NPI: 1649630468
Provider Name (Legal Business Name): MAHA MOSES FPMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2016
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 JAMES ST
SYRACUSE NY
13203-2730
US

IV. Provider business mailing address

4927 W GENESEE ST
CAMILLUS NY
13031-2324
US

V. Phone/Fax

Practice location:
  • Phone: 153-472-4471
  • Fax: 315-472-1759
Mailing address:
  • Phone: 315-996-0204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number709158
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number405929
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: