Basic Information
| Provider Information | |||||||||
| NPI: | 1326697442 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOSS | ||||||||
| FirstName: | MIRANDA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN, FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 955 RIBAUT ROAD | ||||||||
| Address2: | BMAC CREDENTIALING | ||||||||
| City: | BEAUFORT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299025441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435227843 | ||||||||
| FaxNumber: | 8435225678 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 BURNT CHURCH RD STE A | ||||||||
| Address2: | |||||||||
| City: | BLUFFTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299106405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437062185 | ||||||||
| FaxNumber: | 8432995693 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2019 | ||||||||
| LastUpdateDate: | 01/07/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 23205 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | NP6357 | 05 | SC | MEDICAID |