MEDICARE: MS. SANDRA A MOSS CRNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0200X	Pediatric Nurse Practitioner	VP005103D	PA
2	363LA2200X	Adult Health Nurse Practitioner	SP007945	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	232809585	OTHER	PA	HEMATOLOGY
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700315728
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SANDRA A MOSS CRNP

Provider Business Mailing Address
First Line	:	1015 CHESTNUT ST STE 1321
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-4313
Country	:	US
Telephone Number	:	215-955-9854
Fax Number	:	215-955-2342

Provider Business Practice Location Address
First Line	:	1015 CHESTNUT ST STE 1321
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-4313
Country	:	US
Telephone Number	:	215-955-8435
Fax Number	:	215-955-2342

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2017
Last Update Date	:	06/05/2017

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