Provider Demographics
NPI:1851744098
Name:MOSS, CARLY (PA-C)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:MOSS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3728 GUNSTON RD BLDG 918
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22302-2008
Mailing Address - Country:US
Mailing Address - Phone:843-319-2650
Mailing Address - Fax:
Practice Address - Street 1:3001 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CHEVERLY
Practice Address - State:MD
Practice Address - Zip Code:20785-1189
Practice Address - Country:US
Practice Address - Phone:301-618-3779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-22
Last Update Date:2020-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0007646363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant