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1104946383 NPI number — TINA LEE MOON PA-C

NPI Number: 1104946383
Health Care Provider/Practitioner: TINA LEE MOON PA-C

Information about “1104946383” NPI (TINA LEE MOON PA-C) exists in 1104946383 in HTML format HTML  |  1104946383 in plain Text format TXT  |  1104946383 in PDF (Portable Document Format) PDF  |  1104946383 in an XML format XML  formats.

NPI Number : 1104946383 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1104946383",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "MOON",
    "FirstName": "TINA",
    "MiddleName": "LEE",
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": "PA-C",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": "GARY",
    "OtherFirstName": "WAUTHENA",
    "OtherMiddleName": "LEE",
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": "PA-C",
    "OtherLastNameTypeCode": "1",
    "FirstLineMailingAddress": "7809 HEMLOCK AVE",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "HESPERIA",
    "MailingAddressStateName": "CA",
    "MailingAddressPostalCode": "92345-4119",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "951-830-0496",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "1334 W COVINA BLVD",
    "SecondLinePracticeLocationAddress": "SUITE 102",
    "PracticeLocationAddressCityName": "SAN DIMAS",
    "PracticeLocationAddressStateName": "CA",
    "PracticeLocationAddressPostalCode": "91773-3211",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "909-599-8677",
    "PracticeLocationAddressFaxNumber": "909-592-0999",
    "EnumerationDate": "03/30/2007",
    "LastUpdateDate": "07/08/2007",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "F",
    "Gender": "Female",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "363A00000X",
        "TaxonomyName": "Physician Assistant",
        "LicenseNumber": "15164",
        "LicenseNumberStateCode": "CA",
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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