Basic Information
| Provider Information | |||||||||
| NPI: | 1548736960 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOSS | ||||||||
| FirstName: | MELANIE | ||||||||
| MiddleName: | JANE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2003 KOOTENAI HEALTH WAY | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838146051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086256700 | ||||||||
| FaxNumber: | 2086256701 | ||||||||
| Practice Location | |||||||||
| Address1: | 1296 E POLSTON AVE STE C | ||||||||
| Address2: | |||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838545217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086256700 | ||||||||
| FaxNumber: | 2086256701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2018 | ||||||||
| LastUpdateDate: | 08/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1827 | ID | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA1827 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | CS56802 | 01 | ID | CONTROLLED SUBSTANCE | OTHER |