Healthcare Provider Details

I. General information

NPI: 1669941670
Provider Name (Legal Business Name): VONAI MARY MOYO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2018
Last Update Date: 07/04/2024
Certification Date: 07/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 VARICK ST
NEW YORK NY
10013-1917
US

IV. Provider business mailing address

75 VARICK ST
NEW YORK NY
10013-1917
US

V. Phone/Fax

Practice location:
  • Phone: 855-672-2755
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA64233
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberTPPA641
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13550379-1206
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0007023
License Number StateMD
# 5
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10656
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: