Provider Demographics
NPI:1164426680
Name:MOSHER, CYNTHIA M (ANP)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:M
Last Name:MOSHER
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30575 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-0980
Mailing Address - Country:US
Mailing Address - Phone:248-280-8550
Mailing Address - Fax:248-280-8571
Practice Address - Street 1:30575 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-0980
Practice Address - Country:US
Practice Address - Phone:248-280-8550
Practice Address - Fax:248-280-8571
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICM123418363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP10280002Medicare ID - Type Unspecified