Provider Demographics
NPI:1134453418
Name:MOSS, BENJAMIN (PA-C)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:
Last Name:MOSS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:495 SW RAMSEY AVE.
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5681
Mailing Address - Country:US
Mailing Address - Phone:541-476-6644
Mailing Address - Fax:541-472-5673
Practice Address - Street 1:495 SW RAMSEY AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5681
Practice Address - Country:US
Practice Address - Phone:541-476-6644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-20
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA174622363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant