Provider Demographics
NPI:1487945671
Name:MOSER, RANDALL DEAN (LMP)
Entity type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:DEAN
Last Name:MOSER
Suffix:
Gender:M
Credentials:LMP
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 1958
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-1464
Mailing Address - Country:US
Mailing Address - Phone:208-791-1019
Mailing Address - Fax:
Practice Address - Street 1:1018 IDAHO ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-1938
Practice Address - Country:US
Practice Address - Phone:208-791-1019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-22
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID581598-09225700000X
WAMA60111603225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist