Provider Demographics
NPI:1801441985
Name:MOSS, MADISON SPENCER (PTA)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:SPENCER
Last Name:MOSS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 N VILLA SAN MARCO DR UNIT 208
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5193
Mailing Address - Country:US
Mailing Address - Phone:770-324-2058
Mailing Address - Fax:
Practice Address - Street 1:305 N VILLA SAN MARCO DR UNIT 208
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5193
Practice Address - Country:US
Practice Address - Phone:770-324-2058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-06
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA003868225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant