Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207P00000X | Emergency Physician | M-10302 | ID |
N | 207PE0004X | Emergency Medical Services | PENDING | ID |
NPI | 1033384201 |
---|---|
Provider Name | Brian W Moss |
First Address | Eagle, ID 83616-4986 |
Second Address | Caldwell, ID 83605-4802 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/04/2008 |
Last Update Date | 24/01/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
808048600 | (05) | ID |
OTH000 | (02) | ID |