Healthcare Provider Details

I. General information

NPI: 1326774050
Provider Name (Legal Business Name): INNKYU MOON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2022
Last Update Date: 03/15/2026
Certification Date: 03/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 SENATE BLVD
INDIANAPOLIS IN
46202-1239
US

IV. Provider business mailing address

1701 SENATE BLVD
INDIANAPOLIS IN
46202-1239
US

V. Phone/Fax

Practice location:
  • Phone: 888-484-3258
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10005244A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: