Provider Demographics
NPI:1063039816
Name:MOSS, PAUL OTI
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:OTI
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 1:372 BAY LN
Mailing Address - Street 2:
Mailing Address - City:WILLSBORO
Mailing Address - State:NY
Mailing Address - Zip Code:12996-3649
Mailing Address - Country:US
Mailing Address - Phone:518-572-1933
Mailing Address - Fax:
Practice Address - Street 1:372 BAY LN
Practice Address - Street 2:
Practice Address - City:WILLSBORO
Practice Address - State:NY
Practice Address - Zip Code:12996-3649
Practice Address - Country:US
Practice Address - Phone:518-572-1933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-27
Last Update Date:2020-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPRF000406242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist