Basic Information
| Provider Information | |||||||||
| NPI: | 1861460800 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOSS | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | PATRICK | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 PARK ST | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421011784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703931912 | ||||||||
| FaxNumber: | 2703931913 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 PARK ST | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421011760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707451000 | ||||||||
| FaxNumber: | 2703931913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 10/11/2007 | ||||||||
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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 | 367500000X | 1097968 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 000000215853 | 01 | KY | BLUE CROSS | OTHER | 3627422 | 05 | TN | MEDICAID |