Provider Demographics
NPI:1356887640
Name:NATHAN MOSS AGACNP-BC PLLC
Entity type:Organization
Organization Name:NATHAN MOSS AGACNP-BC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:AGACNP-BC
Authorized Official - Phone:208-818-6181
Mailing Address - Street 1:2467 S CLIFFVIEW ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-2989
Mailing Address - Country:US
Mailing Address - Phone:208-818-6181
Mailing Address - Fax:
Practice Address - Street 1:1200 N BEAVER ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3118
Practice Address - Country:US
Practice Address - Phone:208-818-6181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-11
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP8631363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty