Provider Demographics
NPI:1790060846
Name:MOSES, ALISON RAE
Entity Type:Individual
Prefix:
First Name:ALISON
Middle Name:RAE
Last Name:MOSES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALISON
Other - Middle Name:RAE
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 2168
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58107-2168
Mailing Address - Country:US
Mailing Address - Phone:701-234-2119
Mailing Address - Fax:
Practice Address - Street 1:1717 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4939
Practice Address - Country:US
Practice Address - Phone:701-234-2119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND721152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDN720205Medicare PIN
NDN720204Medicare PIN