Provider Demographics
NPI:1396743530
Name:MOSESON, DANE L (MD)
Entity type:Individual
Prefix:DR
First Name:DANE
Middle Name:L
Last Name:MOSESON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3002
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-0302
Mailing Address - Country:US
Mailing Address - Phone:360-414-2048
Mailing Address - Fax:360-575-6749
Practice Address - Street 1:1615 DELAWARE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2310
Practice Address - Country:US
Practice Address - Phone:360-501-3500
Practice Address - Fax:360-501-3555
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00018261208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8943480OtherCRIME VICTIMS
OR160721Medicaid
WA0217053OtherLABOR & IND.
WA8162703Medicaid
WAD33893Medicare UPIN
WA8863529Medicare PIN