1316346950 NPI number — BROOKE ALEXANDRA STEIN MOSS PA-C

Table of content: BROOKE ALEXANDRA STEIN MOSS PA-C (NPI 1316346950)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316346950 NPI number — BROOKE ALEXANDRA STEIN MOSS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOSS
Provider First Name:
BROOKE
Provider Middle Name:
ALEXANDRA STEIN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STEIN
Provider Other First Name:
BROOKE
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1316346950
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
801 YORK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANITOWOC
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54220-4630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-663-9008
Provider Business Mailing Address Fax Number:
920-684-1439

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21410 136TH AVE STE 105A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROGERS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55374-4921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-515-6200
Provider Business Practice Location Address Fax Number:
763-515-6202
Provider Enumeration Date:
08/20/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  11856 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: H400272686 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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