Provider Demographics
NPI:1356591374
Name:MOSS, RUSSELL CHRISTOPHER (P A)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:CHRISTOPHER
Last Name:MOSS
Suffix:
Gender:M
Credentials:P A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:200 PATEWOOD DR STE C100
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-6322
Practice Address - Country:US
Practice Address - Phone:864-454-7422
Practice Address - Fax:864-454-8265
Is Sole Proprietor?:No
Enumeration Date:2008-09-26
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1368363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0728PAMedicaid
SCP00699136OtherRR MEDICARE
SCP00699136OtherRR MEDICARE
SC0728PAMedicaid