Provider Demographics
NPI:1023401619
Name:MOSS, DUSTIN J
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:J
Last Name:MOSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 INTERSTATE DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-2709
Mailing Address - Country:US
Mailing Address - Phone:931-210-5577
Mailing Address - Fax:931-210-5575
Practice Address - Street 1:229 INTERSTATE DR
Practice Address - Street 2:SUITE 103
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-2709
Practice Address - Country:US
Practice Address - Phone:931-210-5577
Practice Address - Fax:931-210-5575
Is Sole Proprietor?:No
Enumeration Date:2015-03-06
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN19695363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily