1427678846 NPI number — SUMMER MOON PA-C

Table of content: SUMMER MOON PA-C (NPI 1427678846)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427678846 NPI number — SUMMER MOON PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOON
Provider First Name:
SUMMER
Provider Middle Name:
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:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427678846
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1465 LANEY WALKER BLVD
Provider Second Line Business Mailing Address:
AF1040
Provider Business Mailing Address City Name:
AUGUSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30912
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-721-9619
Provider Business Mailing Address Fax Number:
706-721-7468

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1465 LANEY WALKER BLVD
Provider Second Line Business Practice Location Address:
PAVILION II, AF 1040
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30912-0002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-721-3448
Provider Business Practice Location Address Fax Number:
706-721-7468
Provider Enumeration Date:
04/26/2020

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PA9113330 . This is a "FLORIDA PA LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 5237 . This is a "SOUTH CAROLINA PA LICENSE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 12183 . This is a "GEORGIA PA LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 107344200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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