Provider Demographics
NPI:1669402004
Name:MOSER, SANDRA L (FNP)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:MOSER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:MO
Mailing Address - Zip Code:65236-1468
Mailing Address - Country:US
Mailing Address - Phone:660-548-3161
Mailing Address - Fax:660-831-3361
Practice Address - Street 1:815 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:MO
Practice Address - Zip Code:65236-1468
Practice Address - Country:US
Practice Address - Phone:660-548-3161
Practice Address - Fax:660-831-3361
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO125899363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO429676216Medicaid
MOMA0185010OtherMEDICARE PTAN
MO429676216Medicaid
MOMA0185010OtherMEDICARE PTAN