Provider Demographics
NPI:1740586429
Name:MOSELEY, KATHRYN RENEE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:RENEE
Last Name:MOSELEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:RENEE
Other - Last Name:DURBIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:6801 MIDDLE RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:VA
Mailing Address - Zip Code:22645-2114
Mailing Address - Country:US
Mailing Address - Phone:540-931-6707
Mailing Address - Fax:
Practice Address - Street 1:510 BUTLER AVE BLDG 413B
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25405-9990
Practice Address - Country:US
Practice Address - Phone:304-263-0811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-28
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003519363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1740586429Medicaid
VA1740586429Medicaid