Provider Demographics
NPI:1356507446
Name:MOUSSA, MAHAMAN LAOUALI (NP)
Entity type:Individual
Prefix:
First Name:MAHAMAN
Middle Name:LAOUALI
Last Name:MOUSSA
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4692 BROWNSBORO ROAD
Mailing Address - Street 2:
Mailing Address - City:WINSTON - SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106
Mailing Address - Country:US
Mailing Address - Phone:336-251-1114
Mailing Address - Fax:336-251-1116
Practice Address - Street 1:4692 BROWNSBORO ROAD
Practice Address - Street 2:
Practice Address - City:WINSTON - SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106
Practice Address - Country:US
Practice Address - Phone:336-251-1114
Practice Address - Fax:336-251-1116
Is Sole Proprietor?:No
Enumeration Date:2008-07-29
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200356363LF0000X
NC5004034363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2593362AOtherMEDICARE