Healthcare Provider Details

I. General information

NPI: 1588865612
Provider Name (Legal Business Name): MOSE MAST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 VIKING DR
VIRGINIA BEACH VA
23452-7316
US

IV. Provider business mailing address

506 VIKING DR
VIRGINIA BEACH VA
23452-7316
US

V. Phone/Fax

Practice location:
  • Phone: 757-304-0686
  • Fax: 757-340-1393
Mailing address:
  • Phone: 757-304-0686
  • Fax: 757-340-1393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: