Provider Demographics
NPI:1972973634
Name:MOSES, KATIE (PA-C)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:MOSES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:NICOLE
Other - Last Name:O'DONNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 FEDERAL ST
Mailing Address - Street 2:STE SW200
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1155
Mailing Address - Country:US
Mailing Address - Phone:856-968-7433
Mailing Address - Fax:856-968-8366
Practice Address - Street 1:3 COOPER PLZ
Practice Address - Street 2:SUITE NUMBER 411
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-1438
Practice Address - Country:US
Practice Address - Phone:856-968-7433
Practice Address - Fax:856-968-8366
Is Sole Proprietor?:No
Enumeration Date:2015-10-06
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00379700363A00000X
PAMA057891363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical