Healthcare Provider Details

I. General information

NPI: 1295563161
Provider Name (Legal Business Name): JUSTIN MOY DNP, CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2024
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 WATERLOO RD STE 200
COLUMBIA MD
21045-2641
US

IV. Provider business mailing address

7580 BUCKINGHAM BLVD STE 220
HANOVER MD
21076-3210
US

V. Phone/Fax

Practice location:
  • Phone: 410-740-2900
  • Fax: 410-740-2955
Mailing address:
  • Phone: 410-729-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberR239415
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberR239415
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: