Provider Demographics
NPI:1578784005
Name:MOSHER, KELLI ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:ANN
Last Name:MOSHER
Suffix:
Gender:F
Credentials:PA-C
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 14878
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27415
Mailing Address - Country:US
Mailing Address - Phone:336-626-0033
Mailing Address - Fax:
Practice Address - Street 1:713-B S FAYETTEVILLE STREET
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203
Practice Address - Country:US
Practice Address - Phone:336-626-0033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103547363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC7336OtherMEDCOST
NCP00033893OtherRAILROAD MEDICARE
NC2758121Medicare ID - Type Unspecified
NCC7336OtherMEDCOST