Provider Demographics
NPI:1679660187
Name:MOSS, TARA SPENCER (PAC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:SPENCER
Last Name:MOSS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 NINTH STREET
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521
Mailing Address - Country:US
Mailing Address - Phone:707-826-8633
Mailing Address - Fax:707-826-8638
Practice Address - Street 1:770 10TH STREET
Practice Address - Street 2:
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521
Practice Address - Country:US
Practice Address - Phone:707-826-8610
Practice Address - Fax:707-826-8623
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17518363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS53834Medicare UPIN