Healthcare Provider Details

I. General information

NPI: 1386022630
Provider Name (Legal Business Name): AMBER MOSS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2015
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 PAR DR
GILLETTE WY
82718-7623
US

IV. Provider business mailing address

619 PAR DR
GILLETTE WY
82718-7623
US

V. Phone/Fax

Practice location:
  • Phone: 423-620-8971
  • Fax:
Mailing address:
  • Phone: 423-620-8971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0102207261
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO4807
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number117-T2
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: