Provider Demographics
NPI:1942671730
Name:MOSLEY, COURTNEY LAYNE
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LAYNE
Last Name:MOSLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:LAYNE
Other - Last Name:REYNOLDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3901 PARKWAY CIR
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-6362
Mailing Address - Country:US
Mailing Address - Phone:479-587-1700
Mailing Address - Fax:479-587-1366
Practice Address - Street 1:3901 PARKWAY CIR
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-6362
Practice Address - Country:US
Practice Address - Phone:479-587-1700
Practice Address - Fax:479-587-1366
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-19
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA312218363AM0700X
ARPA-642363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR210351795Medicaid