Provider Demographics
NPI:1225098510
Name:MOSS, ROCKSAN (PA)
Entity Type:Individual
Prefix:
First Name:ROCKSAN
Middle Name:
Last Name:MOSS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-2534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:844-848-5854
Practice Address - Street 1:508 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-2534
Practice Address - Country:US
Practice Address - Phone:801-773-8644
Practice Address - Fax:844-848-5854
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004380363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA638560621AMedicaid
GA638560621CMedicaid
UT9603746-1206OtherSTATE LICENSE
GA10059174OtherAMERIGROUP
GA638560621DMedicaid
GA638560621EMedicaid
GA638560621CMedicaid
GA638560621DMedicaid
GA638560621EMedicaid