Provider Demographics
NPI:1417507393
Name:MOSS, ZACHARY GORDON
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:GORDON
Last Name:MOSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ZACK
Other - Middle Name:GORDON
Other - Last Name:MOSS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:223 PINE BRANCH CIR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-2121
Mailing Address - Country:US
Mailing Address - Phone:706-566-2569
Mailing Address - Fax:
Practice Address - Street 1:223 PINE BRANCH CIR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-2121
Practice Address - Country:US
Practice Address - Phone:706-566-2569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA390200000X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program