Provider Demographics
NPI:1306553367
Name:MOSS, MARSHALL
Entity type:Individual
Prefix:MR
First Name:MARSHALL
Middle Name:
Last Name:MOSS
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:MARSHALL
Other - Middle Name:
Other - Last Name:MOSS
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:INDEPENDANT PROVIDER
Mailing Address - Street 1:3149 NAVARRE AVE APT 3C
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:OH
Mailing Address - Zip Code:43616-3359
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10655 W STATE ROUTE 2 LOT 23
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:OH
Practice Address - Zip Code:43449-9304
Practice Address - Country:US
Practice Address - Phone:567-225-2928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH139098146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, ParamedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH139098OtherPARAMEDIC