Provider Demographics
NPI:1407182421
Name:MOSLEY, STEPHEN JACOB (PA-C)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:JACOB
Last Name:MOSLEY
Suffix:
Gender:M
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 1:64 PINE KNOLL LN
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-4588
Mailing Address - Country:US
Mailing Address - Phone:770-757-2190
Mailing Address - Fax:
Practice Address - Street 1:64 PINE KNOLL LN
Practice Address - Street 2:
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-4588
Practice Address - Country:US
Practice Address - Phone:770-757-2190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-27
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1264363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical