Provider Demographics
NPI:1780302935
Name:MOSES, AIRSTON SMALL (FNP)
Entity type:Individual
Prefix:
First Name:AIRSTON
Middle Name:SMALL
Last Name:MOSES
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 1:216 E PRESIDENT AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-3516
Mailing Address - Country:US
Mailing Address - Phone:662-897-5070
Mailing Address - Fax:
Practice Address - Street 1:840 N OAK AVE
Practice Address - Street 2:
Practice Address - City:RULEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38771-3227
Practice Address - Country:US
Practice Address - Phone:662-756-4024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-15
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS905497363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily