Provider Demographics
NPI:1396713194
Name:MOSS, KIRK TRACY (MD)
Entity type:Individual
Prefix:
First Name:KIRK
Middle Name:TRACY
Last Name:MOSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14TH MDG, 201 INDEPENDENCE DRIVE, BLDG 1100
Mailing Address - Street 2:COLUMBUS AFB, MS 39710
Mailing Address - City:FPO
Mailing Address - State:AA
Mailing Address - Zip Code:93246
Mailing Address - Country:US
Mailing Address - Phone:6624-343-9710
Mailing Address - Fax:
Practice Address - Street 1:14TH MDG
Practice Address - Street 2:201 INDEPENDENCE DR
Practice Address - City:COLUMBUS AFB
Practice Address - State:MS
Practice Address - Zip Code:39710
Practice Address - Country:US
Practice Address - Phone:662-434-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2838207Q00000X
AZ31364207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A0348OtherBLUE CROSS SUB
AKMD2838Medicaid
AK152106Medicare ID - Type Unspecified
G35683Medicare UPIN
A0348OtherBLUE CROSS SUB