Healthcare Provider Details

I. General information

NPI: 1063906857
Provider Name (Legal Business Name): STEPHAN MICHAEL MOSS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2018
Last Update Date: 11/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 W HOSPITAL RD
BRIGHAM CITY UT
84302-3006
US

IV. Provider business mailing address

600 W HOSPITAL RD
BRIGHAM CITY UT
84302-3006
US

V. Phone/Fax

Practice location:
  • Phone: 435-734-2041
  • Fax:
Mailing address:
  • Phone: 435-734-2041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10566698-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number10566698-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: