Provider Demographics
NPI:1063906857
Name:MOSS, STEPHAN MICHAEL
Entity type:Individual
Prefix:
First Name:STEPHAN
Middle Name:MICHAEL
Last Name:MOSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 W HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-3006
Mailing Address - Country:US
Mailing Address - Phone:435-734-2041
Mailing Address - Fax:
Practice Address - Street 1:600 W HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-3006
Practice Address - Country:US
Practice Address - Phone:435-734-2041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10566698-3102163WE0003X
UT10566698-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT10566698-4405OtherLICENSE