Basic Information
| Provider Information | |||||||||
| NPI: | 1285605600 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOSHREF | ||||||||
| FirstName: | WEISS | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2601 OSWELL ST | ||||||||
| Address2: | STE101 | ||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 933063156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6618729999 | ||||||||
| FaxNumber: | 6616165748 | ||||||||
| Practice Location | |||||||||
| Address1: | 2601 OSWELL STREET | ||||||||
| Address2: | SUITE101 | ||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 933063156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6618729999 | ||||||||
| FaxNumber: | 6616165748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 02/02/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA18322 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | PA18322 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1053345991 | 05 | CA | MEDICAID |