Provider Demographics
NPI:1720551633
Name:MOSES, ANDREA DAWN (FNP)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:DAWN
Last Name:MOSES
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:BAILES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4605 MACCORKLE AVE SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1311
Mailing Address - Country:US
Mailing Address - Phone:304-414-4800
Mailing Address - Fax:
Practice Address - Street 1:6A BANK ST
Practice Address - Street 2:
Practice Address - City:NITRO
Practice Address - State:WV
Practice Address - Zip Code:25143-1708
Practice Address - Country:US
Practice Address - Phone:304-306-3058
Practice Address - Fax:304-306-3059
Is Sole Proprietor?:No
Enumeration Date:2019-01-03
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAPRN61718NP-C363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVB441OtherMEDICARE GROUP