Provider Demographics
NPI:1366170375
Name:MOSES, SAMUEL (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:MOSES
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:SAMUEL
Other - Middle Name:MASILA
Other - Last Name:MOSES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:31405 18TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-5433
Mailing Address - Country:US
Mailing Address - Phone:817-805-6673
Mailing Address - Fax:
Practice Address - Street 1:31405 18TH AVE S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-5433
Practice Address - Country:US
Practice Address - Phone:253-681-6640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-09
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61335567363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health