Provider Demographics
NPI:1700360823
Name:MOSELEY, KOBI B (PA)
Entity Type:Individual
Prefix:
First Name:KOBI
Middle Name:B
Last Name:MOSELEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KOBI
Other - Middle Name:BURNETT
Other - Last Name:PETERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:4333 W ST JOE HWY
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-4100
Mailing Address - Country:US
Mailing Address - Phone:517-321-1525
Mailing Address - Fax:517-321-7059
Practice Address - Street 1:4333 W ST JOE HWY
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-4100
Practice Address - Country:US
Practice Address - Phone:517-321-1525
Practice Address - Fax:517-321-7059
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MI5601008921363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1155893OtherNCCPA