Provider Demographics
NPI:1437520954
Name:MOSS, JEREMIAH JOHN
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:JOHN
Last Name:MOSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 16TH STREET
Mailing Address - Street 2:PO BOX 311
Mailing Address - City:HOXIE
Mailing Address - State:KS
Mailing Address - Zip Code:67740
Mailing Address - Country:US
Mailing Address - Phone:785-657-1411
Mailing Address - Fax:
Practice Address - Street 1:1409 16TH STREET
Practice Address - Street 2:
Practice Address - City:HOXIE
Practice Address - State:KS
Practice Address - Zip Code:67740
Practice Address - Country:US
Practice Address - Phone:785-657-1411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-09
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-02422225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSXSB898139036OtherBLUE CROSS BLUE SHIELD