Provider Demographics
NPI:1922523984
Name:MOSS, JONATHAN MAURICE
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:MAURICE
Last Name:MOSS
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JONATHAN
Other - Middle Name:MAURICE
Other - Last Name:MOSS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DRIVER
Mailing Address - Street 1:7512 BOYDTON PLANK RD
Mailing Address - Street 2:
Mailing Address - City:NORTH DINWIDDIE
Mailing Address - State:VA
Mailing Address - Zip Code:23803-7354
Mailing Address - Country:US
Mailing Address - Phone:804-943-1549
Mailing Address - Fax:
Practice Address - Street 1:7512 BOYDTON PLANK RD
Practice Address - Street 2:
Practice Address - City:NORTH DINWIDDIE
Practice Address - State:VA
Practice Address - Zip Code:23803-7354
Practice Address - Country:US
Practice Address - Phone:804-943-1549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-10
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA$$$$$$$$$Medicaid