Provider Demographics
NPI:1891050068
Name:MOSS, MARK LEE (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:LEE
Last Name:MOSS
Suffix:
Gender:M
Credentials:PT
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Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:390 E PARKCENTER BLVD
Practice Address - Street 2:SUITE 130
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-6662
Practice Address - Country:US
Practice Address - Phone:208-433-9211
Practice Address - Fax:208-433-9241
Is Sole Proprietor?:No
Enumeration Date:2012-07-12
Last Update Date:2014-10-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IDPT 3018225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0330322OtherWA L&I
ID1891050068Medicaid
ID20001648Medicare PIN