Provider Demographics
NPI:1164103834
Name:GAWAIN, MOSS
Entity type:Individual
Prefix:
First Name:MOSS
Middle Name:
Last Name:GAWAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALESSANDRA
Other - Middle Name:GABRIELLE
Other - Last Name:RAGUSIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4103 S YALE AVE STE B
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-6002
Mailing Address - Country:US
Mailing Address - Phone:918-382-7300
Mailing Address - Fax:918-382-7302
Practice Address - Street 1:2548 E KENOSHA ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74014-6712
Practice Address - Country:US
Practice Address - Phone:918-355-0993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-26
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator