Provider Demographics
NPI:1457428195
Name:MOSS, ANGELA SUE (MD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:SUE
Last Name:MOSS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 JMZ DR
Mailing Address - Street 2:
Mailing Address - City:GORDONSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38563-2152
Mailing Address - Country:US
Mailing Address - Phone:615-683-1070
Mailing Address - Fax:615-683-1079
Practice Address - Street 1:126 JMZ DR
Practice Address - Street 2:
Practice Address - City:GORDONSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38563-2152
Practice Address - Country:US
Practice Address - Phone:615-683-1070
Practice Address - Fax:615-683-1079
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN35031207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3874872Medicaid
TNH62910Medicare UPIN
TN3874872Medicaid