Provider Demographics
NPI:1437232659
Name:MOSS, ALEX C (PAC)
Entity type:Individual
Prefix:
First Name:ALEX
Middle Name:C
Last Name:MOSS
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:ID
Mailing Address - Zip Code:83254-1544
Mailing Address - Country:US
Mailing Address - Phone:208-847-2878
Mailing Address - Fax:208-847-2340
Practice Address - Street 1:465 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:ID
Practice Address - Zip Code:83254-1544
Practice Address - Country:US
Practice Address - Phone:208-847-2878
Practice Address - Fax:208-847-2340
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA516363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010148620OtherBLUE SHIELD IDAHO INDIVID
ID807007000Medicaid
IDPAWD7OtherBLUE CROSS OF IDAHO INDIV
IDP00477878OtherMEDICARE RAILROAD
ID8L568OtherBLUE CROSS IDAHO GROUP NO
ID8L568OtherBLUE CROSS IDAHO GROUP NO
ID1378722Medicare PIN
IDP00477878OtherMEDICARE RAILROAD