Healthcare Provider Details

I. General information

NPI: 1629388681
Provider Name (Legal Business Name): EMILY MOYO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2010
Last Update Date: 11/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6321 UTRECHT AVE.
BROOKLYN NY
11219
US

IV. Provider business mailing address

6321 NEW UTRECHT AVE # NY11219
BROOKLYN NY
11219-5425
US

V. Phone/Fax

Practice location:
  • Phone: 212-774-3219
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0032821
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: