Provider Demographics
NPI:1891188330
Name:MOSES, ISAAC EROMOSELE
Entity Type:Individual
Prefix:
First Name:ISAAC
Middle Name:EROMOSELE
Last Name:MOSES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3823 64TH AVE
Mailing Address - Street 2:APT # 4
Mailing Address - City:LANDOVERHILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20784-1876
Mailing Address - Country:US
Mailing Address - Phone:240-413-0204
Mailing Address - Fax:
Practice Address - Street 1:3823 64TH AVE
Practice Address - Street 2:APT # 4
Practice Address - City:LANDOVER HILLS
Practice Address - State:MD
Practice Address - Zip Code:20784-1830
Practice Address - Country:US
Practice Address - Phone:240-413-0204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-09
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA11062374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide