Provider Demographics
NPI:1316346950
Name:MOSS, BROOKE ALEXANDRA STEIN (PA-C)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ALEXANDRA STEIN
Last Name:MOSS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:A
Other - Last Name:STEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:21410 136TH AVE STE 105A
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374-4921
Practice Address - Country:US
Practice Address - Phone:763-515-6200
Practice Address - Fax:763-515-6202
Is Sole Proprietor?:No
Enumeration Date:2014-08-20
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11856363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400272686Medicaid