Provider Demographics
NPI:1437128626
Name:MOSS, STEVEN B (PA)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:B
Last Name:MOSS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40822 N HARBOUR TOWN WAY
Mailing Address - Street 2:
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-1819
Mailing Address - Country:US
Mailing Address - Phone:401-480-9077
Mailing Address - Fax:
Practice Address - Street 1:14780 W MOUNTAIN VIEW BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-4799
Practice Address - Country:US
Practice Address - Phone:623-374-7774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4818363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9004001Medicaid
RI9004001Medicaid
RI979004001Medicare ID - Type Unspecified