Provider Demographics
NPI:1023068780
Name:MOSS, LAURA C (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:C
Last Name:MOSS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 ESTHER ST
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-9529
Mailing Address - Country:US
Mailing Address - Phone:503-554-4325
Mailing Address - Fax:
Practice Address - Street 1:101 W 8TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2307
Practice Address - Country:US
Practice Address - Phone:509-474-4818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2015-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD1505152084A0401X
WAMD 391292084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8395154Medicaid
WAAB32999OtherMEDICARE GROUP
WAG35759Medicare UPIN
WAG8861721Medicare PIN
WA8803829Medicare PIN