Provider Demographics
NPI:1487664231
Name:MOSER, PHILLIP NATHAN (CRNA)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:NATHAN
Last Name:MOSER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 57
Mailing Address - Street 2:
Mailing Address - City:NEW ULM
Mailing Address - State:TX
Mailing Address - Zip Code:78950-0057
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:643 INTERSTATE 45 S STE B
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77340-6434
Practice Address - Country:US
Practice Address - Phone:979-992-2808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX225703367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX119974706Medicaid
TX82516UOtherBLUE CROSS/ BLUE SHIELD
R82571OtherCHAMPUS
CK3380OtherRAILROAD MEDICARE
225703OtherTEXAS WORKER'S COMP
225703OtherTEXAS WORKER'S COMP
TX82516UOtherBLUE CROSS/ BLUE SHIELD