MEDICARE: CARSON WALTER MOOCK FNP

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	163W00000X	Registered Nurse	0001299817	VA
2	390200000X	Student in an Organized Health Care Education/Training Program		VA

General Provider Information

NPI Number	:	1467309252
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARSON WALTER MOOCK FNP

Provider Business Mailing Address
First Line	:	6104 ROSELAWN RD
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24018-7608
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6104 ROSELAWN RD
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24018-7608
Country	:	US
Telephone Number	:	540-314-1101
Fax Number	:

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

Provider Enumeration Date	:	03/12/2026
Last Update Date	:	03/12/2026

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