Healthcare Provider Details

I. General information

NPI: 1144462631
Provider Name (Legal Business Name): COASTAL CAROLINA NEONATOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2009
Last Update Date: 10/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 S 17TH ST
WILMINGTON NC
28401-7407
US

IV. Provider business mailing address

2131 S 17TH ST
WILMINGTON NC
28401-7407
US

V. Phone/Fax

Practice location:
  • Phone: 910-772-9202
  • Fax: 910-772-9452
Mailing address:
  • Phone: 910-772-9202
  • Fax: 910-772-9452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number
License Number StateNC

VIII. Authorized Official

Name: DR. FERNANDO R MOYA
Title or Position: INCORPORATOR
Credential: MD
Phone: 910-772-9202