Provider Demographics
NPI:1700315728
Name:MOSS, SANDRA A (CRNP)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:A
Last Name:MOSS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 CHESTNUT ST STE 1321
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4313
Mailing Address - Country:US
Mailing Address - Phone:215-955-9854
Mailing Address - Fax:215-955-2342
Practice Address - Street 1:1015 CHESTNUT ST STE 1321
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4313
Practice Address - Country:US
Practice Address - Phone:215-955-8435
Practice Address - Fax:215-955-2342
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAVP005103D363LP0200X
PASP007945363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA232809585OtherHEMATOLOGY
PA23209585Medicaid