Provider Demographics
NPI:1013469873
Name:MOSS, DAVIA GAELIN (NP)
Entity Type:Individual
Prefix:
First Name:DAVIA
Middle Name:GAELIN
Last Name:MOSS
Suffix:
Gender:F
Credentials:NP
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Other - Credentials:
Mailing Address - Street 1:725 EAST ADAMS ST
Mailing Address - Street 2:4TH FL
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-2576
Mailing Address - Country:US
Mailing Address - Phone:315-464-5831
Mailing Address - Fax:314-464-2030
Practice Address - Street 1:725 EAST ADAMS ST
Practice Address - Street 2:4TH FL
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2576
Practice Address - Country:US
Practice Address - Phone:315-464-5831
Practice Address - Fax:314-464-2030
Is Sole Proprietor?:No
Enumeration Date:2016-10-27
Last Update Date:2023-05-25
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Provider Licenses
StateLicense IDTaxonomies
NY645775163W00000X
NYF340815363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04635810Medicaid