Provider Demographics
NPI:1871667089
Name:MOSIMAN, SID (PT)
Entity Type:Individual
Prefix:MR
First Name:SID
Middle Name:
Last Name:MOSIMAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 S RIO GRANDE AVE
Mailing Address - Street 2:
Mailing Address - City:AZTEC
Mailing Address - State:NM
Mailing Address - Zip Code:87410-2260
Mailing Address - Country:US
Mailing Address - Phone:505-334-9616
Mailing Address - Fax:505-334-7343
Practice Address - Street 1:604 S RIO GRANDE AVE
Practice Address - Street 2:
Practice Address - City:AZTEC
Practice Address - State:NM
Practice Address - Zip Code:87410-2260
Practice Address - Country:US
Practice Address - Phone:505-334-9616
Practice Address - Fax:505-334-7343
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1025225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMK0972Medicaid
NMR12859Medicare UPIN