Provider Demographics
NPI:1336739440
Name:MOSES, JORDAN (APRN)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:MOSES
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 MONTAUK HWY STE 1
Mailing Address - Street 2:
Mailing Address - City:EAST MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11940-1236
Mailing Address - Country:US
Mailing Address - Phone:631-874-2900
Mailing Address - Fax:
Practice Address - Street 1:516 MONTAUK HWY STE 1
Practice Address - Street 2:
Practice Address - City:EAST MORICHES
Practice Address - State:NY
Practice Address - Zip Code:11940-1236
Practice Address - Country:US
Practice Address - Phone:631-874-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-22
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1029221363LF0000X
NY348188363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily