Provider Demographics
NPI:1043207756
Name:MOSS, MEREDITH A (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MEREDITH
Middle Name:A
Last Name:MOSS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 E 32ND ST
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-7287
Mailing Address - Country:US
Mailing Address - Phone:575-538-2981
Mailing Address - Fax:575-388-3373
Practice Address - Street 1:2802 N ALVERNON WAY STE 200
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-1500
Practice Address - Country:US
Practice Address - Phone:520-326-0850
Practice Address - Fax:520-326-0849
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA880363A00000X
NMPA2008-0068363A00000X
AK714363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM30179521Medicaid
NM30179521Medicaid
Q00395Medicare UPIN