Individual
MARK LEE MOSS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
P.T.
Contact information
Practice address
390 E PARKCENTER BLVD, SUITE 130, BOISE, ID 83706-6662
(208) 433-9211
(208) 433-9241
Mailing address
16083 SW UPPER BOONES FERRY RD, SUITE 300, TIGARD, OR 97224-7736
(800) 219-8835
(503) 639-9699
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
PT 3018
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0330322
WA L&I
ID
05
—
1891050068
—
ID
Enumeration date
07/12/2012
Last updated
10/10/2014
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