Basic Information
| Provider Information | |||||||||
| NPI: | 1437128626 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOSS | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40822 N HARBOUR TOWN WAY | ||||||||
| Address2: | |||||||||
| City: | ANTHEM | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850861819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014809077 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14780 W MOUNTAIN VIEW BLVD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | SURPRISE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853744799 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6233747774 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2006 | ||||||||
| LastUpdateDate: | 01/08/2015 | ||||||||
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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 | 363A00000X | 4818 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 9004001 | 05 | RI | MEDICAID |