Healthcare Provider Details

I. General information

NPI: 1568342475
Provider Name (Legal Business Name): JONATHAN MOCTEZUMA CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2025
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 S ERIE ST STE D
MERCER PA
16137-1555
US

IV. Provider business mailing address

1034 GROVE ST
MEADVILLE PA
16335-2945
US

V. Phone/Fax

Practice location:
  • Phone: 724-662-4155
  • Fax: 724-662-2352
Mailing address:
  • Phone: 814-333-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberSP036708
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN759448
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: