Provider Demographics
NPI:1689130106
Name:MOSS, STEPHEN (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:MOSS
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S RIVERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:BIXBY
Mailing Address - State:OK
Mailing Address - Zip Code:74008-4938
Mailing Address - Country:US
Mailing Address - Phone:918-366-1709
Mailing Address - Fax:
Practice Address - Street 1:601 S RIVERVIEW DR
Practice Address - Street 2:
Practice Address - City:BIXBY
Practice Address - State:OK
Practice Address - Zip Code:74008-4938
Practice Address - Country:US
Practice Address - Phone:918-366-1709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7162255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer