Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207YX0905X | Otolaryngology/Facial Plastic Surgery | H3795 | TX |
NPI | 1851399463 |
---|---|
Provider Name | Dr. Jesse Moss JR. |
First Address | Live Oak, TX 78233-3269 |
Second Address | Live Oak, TX 78233-3269 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/07/2005 |
Last Update Date | 17/09/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
E03389 | (02) | TX |