Healthcare Provider Details

I. General information

NPI: 1033620323
Provider Name (Legal Business Name): CHARLOTTE DELANE MOSS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2017
Last Update Date: 04/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 S MIDLOTHIAN PKWY
MIDLOTHIAN TX
76065-5591
US

IV. Provider business mailing address

2121 RIVERFOREST DR
ARLINGTON TX
76017-1636
US

V. Phone/Fax

Practice location:
  • Phone: 469-800-9600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA11485
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPA11485
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: