MEDICARE: NATHANIEL RAY MOXON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	86817-20	WI

General Provider Information

NPI Number	:	1275050361
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATHANIEL RAY MOXON

Provider Business Mailing Address
First Line	:	10425 W NORTH AVE STE 140
Second Line	:
City	:	WAUWATOSA
State	:	WI
Zip	:	53226-2400
Country	:	US
Telephone Number	:	414-877-6414
Fax Number	:

Provider Business Practice Location Address
First Line	:	10425 W NORTH AVE STE 140
Second Line	:
City	:	WAUWATOSA
State	:	WI
Zip	:	53226-2400
Country	:	US
Telephone Number	:	414-877-6414
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2017
Last Update Date	:	01/25/2026

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