Basic Information
Provider Information
NPI: 1033559372
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MOSER
FirstName: AMBER
MiddleName: LEE
NamePrefix: MRS.
NameSuffix:  
Credential: LPTA
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1500 E CARDINAL DR
Address2:  
City: FAYETTEVILLE
State: AR
PostalCode: 727034154
CountryCode: US
TelephoneNumber: 4798716849
FaxNumber:  
Practice Location
Address1: 1923 E JOYCE BLVD
Address2:  
City: FAYETTEVILLE
State: AR
PostalCode: 727035293
CountryCode: US
TelephoneNumber: 4794427220
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/01/2013
LastUpdateDate: 07/01/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225200000X2614ARY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant 

No ID Information.


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