Provider Demographics
NPI:1902982994
Name:MOSES, JOHANNA STUART MARY (DC)
Entity type:Individual
Prefix:DR
First Name:JOHANNA
Middle Name:STUART MARY
Last Name:MOSES
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6578 NEW YORK STATE ROUTE 12
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:NY
Mailing Address - Zip Code:13815-0000
Mailing Address - Country:US
Mailing Address - Phone:607-334-4703
Mailing Address - Fax:607-334-4703
Practice Address - Street 1:6578 NEW YORK STATE ROUTE 12
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:NY
Practice Address - Zip Code:13815-0000
Practice Address - Country:US
Practice Address - Phone:607-334-4703
Practice Address - Fax:607-334-4703
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX004611-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC04611-2OtherNYS WORKERS COMPENSATION
NYBB0687Medicare ID - Type UnspecifiedPARTICIPATING PROVIDER