Healthcare Provider Details

I. General information

NPI: 1356250112
Provider Name (Legal Business Name): HEESEO MOON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2026
Last Update Date: 09/05/2026
Certification Date: 09/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

548 BROOKSIDE DR
MACON GA
31210-8029
US

IV. Provider business mailing address

548 BROOKSIDE DR
MACON GA
31210-8029
US

V. Phone/Fax

Practice location:
  • Phone: 434-291-4257
  • Fax:
Mailing address:
  • Phone: 434-291-4257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN719364
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: