Healthcare Provider Details

I. General information

NPI: 1407469265
Provider Name (Legal Business Name): RANDALL MOON FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2020
Last Update Date: 11/26/2025
Certification Date: 11/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2060 S COLORADO ST
LOCKHART TX
78644-3951
US

IV. Provider business mailing address

PO BOX 1890
GONZALES TX
78629-1390
US

V. Phone/Fax

Practice location:
  • Phone: 830-494-4001
  • Fax: 877-599-5676
Mailing address:
  • Phone: 830-672-6511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1011256
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: