Provider Demographics
NPI:1588118111
Name:MOSS, NATHAN ALAN (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:ALAN
Last Name:MOSS
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2467 S CLIFFVIEW ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-2989
Mailing Address - Country:US
Mailing Address - Phone:208-818-6181
Mailing Address - Fax:
Practice Address - Street 1:1215 N BEAVER ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3126
Practice Address - Country:US
Practice Address - Phone:928-773-2200
Practice Address - Fax:928-773-2151
Is Sole Proprietor?:No
Enumeration Date:2016-08-11
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP8631363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care