Healthcare Provider Details

I. General information

NPI: 1952308603
Provider Name (Legal Business Name): CHARLES ALBERT MOXIN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 01/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4025 SOUTHCROSS
SAN ANTONIO TX
78222-3640
US

IV. Provider business mailing address

4025 E SOUTHCROSS BLVD STE 7
SAN ANTONIO TX
78222-3640
US

V. Phone/Fax

Practice location:
  • Phone: 210-333-1255
  • Fax: 210-333-8496
Mailing address:
  • Phone: 210-333-1255
  • Fax: 210-333-8496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA00887
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: