Provider Demographics
NPI:1104658749
Name:MOOS, DEREK (AGPCNP-BC)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:MOOS
Suffix:
Gender:M
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2977 WEST
Mailing Address - Street 2:2600 SOUTH
Mailing Address - City:SYRACUSE
Mailing Address - State:UT
Mailing Address - Zip Code:84075
Mailing Address - Country:US
Mailing Address - Phone:801-682-6170
Mailing Address - Fax:
Practice Address - Street 1:2977 WEST
Practice Address - Street 2:2600 SOUTH
Practice Address - City:SYRACUSE
Practice Address - State:UT
Practice Address - Zip Code:84075
Practice Address - Country:US
Practice Address - Phone:801-682-6170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-14
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6586693-4405363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care