Provider Demographics
NPI:1508120247
Name:MOSS, MALISA JOSEPHINE (DO)
Entity Type:Individual
Prefix:DR
First Name:MALISA
Middle Name:JOSEPHINE
Last Name:MOSS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 432
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41502-0432
Mailing Address - Country:US
Mailing Address - Phone:606-430-2207
Mailing Address - Fax:606-218-7507
Practice Address - Street 1:911 BYPASS RD BLDG A
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-1689
Practice Address - Country:US
Practice Address - Phone:606-430-2207
Practice Address - Fax:606-218-7507
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-27
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK110662207V00000X
MI5101019746207V00000X
KY04723207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology