Provider Demographics
NPI:1700338704
Name:MOSS, CHARLOTTE BAKER (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CHARLOTTE
Middle Name:BAKER
Last Name:MOSS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CHARLOTTE
Other - Middle Name:GARMAN
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:901-227-3255
Mailing Address - Fax:
Practice Address - Street 1:501 MARSHALL ST STE G07
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1651
Practice Address - Country:US
Practice Address - Phone:601-968-3238
Practice Address - Fax:601-968-3237
Is Sole Proprietor?:No
Enumeration Date:2016-10-26
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00329363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant