Basic Information
| Provider Information | |||||||||
| NPI: | 1962486829 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOSS | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 S CASCADE AVE STE 140 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809031604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7198666568 | ||||||||
| FaxNumber: | 7195382999 | ||||||||
| Practice Location | |||||||||
| Address1: | 715 N WEBER ST | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809031091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194736115 | ||||||||
| FaxNumber: | 7194722577 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2005 | ||||||||
| LastUpdateDate: | 01/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 21451 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | CRNA0841 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | APN.0992028-CRNA | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 07107485 | 05 | CO | MEDICAID |