Provider Demographics
NPI:1023522778
Name:MOSER, MADISON (PTA)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:MOSER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1318 ODELL AVE
Mailing Address - Street 2:
Mailing Address - City:THERMOPOLIS
Mailing Address - State:WY
Mailing Address - Zip Code:82443-2543
Mailing Address - Country:US
Mailing Address - Phone:620-376-8385
Mailing Address - Fax:
Practice Address - Street 1:1210 CANYON HILLS RD
Practice Address - Street 2:
Practice Address - City:THERMOPOLIS
Practice Address - State:WY
Practice Address - Zip Code:82443-3137
Practice Address - Country:US
Practice Address - Phone:307-864-5591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-03300225200000X
WY0968225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant