Provider Demographics
NPI:1821060856
Name:MOSS, NICOLE JULIANA (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:JULIANA
Last Name:MOSS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2931 N TENAYA WAY
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-0456
Mailing Address - Country:US
Mailing Address - Phone:702-233-2123
Mailing Address - Fax:702-233-0398
Practice Address - Street 1:2931 N TENAYA WAY
Practice Address - Street 2:SUITE 204
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0456
Practice Address - Country:US
Practice Address - Phone:702-233-2123
Practice Address - Fax:702-233-0398
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9708207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2018759Medicaid
NV3102759Medicaid
NV35052Medicare ID - Type Unspecified
H40678Medicare UPIN