Basic Information
| Provider Information | |||||||||
| NPI: | 1013993229 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOSER | ||||||||
| FirstName: | P | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5811 GLENWOOD AVE | ||||||||
| Address2: | SUITE #101 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276126260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197812116 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4325 GLENWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276124532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197824100 | ||||||||
| FaxNumber: | 9197879573 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2005 | ||||||||
| LastUpdateDate: | 08/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1026 | NC | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 890939 | 05 | NC | MEDICAID |