Provider Demographics
NPI:1831138692
Name:MOSS, STANLEY WARREN (MD)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:WARREN
Last Name:MOSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:520 S EAGLE RD
Mailing Address - Street 2:STE 1201
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6351
Mailing Address - Country:US
Mailing Address - Phone:208-855-9600
Mailing Address - Fax:208-855-9603
Practice Address - Street 1:520 S EAGLE RD
Practice Address - Street 2:STE 1201
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6351
Practice Address - Country:US
Practice Address - Phone:208-855-9600
Practice Address - Fax:208-855-9603
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2014-01-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IDM4403207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0180620001Medicare NSC
IDC36897Medicare UPIN
ID1114777Medicare PIN