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General NPI Number Information
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NPI Number | 1104946383
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Entity Type | Individual
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Provider Name | TINA LEE MOON PA-C
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Gender | Female
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Dates
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Enumeration Date | 03/30/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1334 W COVINA BLVD SUITE 102
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City | SAN DIMAS
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State | CA
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Zip | 91773-3211
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Country | US
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Telephone | 909-599-8677
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Fax | 909-592-0999
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Provider Business Mailing Address
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Address Line | 7809 HEMLOCK AVE
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City | HESPERIA
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State | CA
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Zip | 92345-4119
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Country | US
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Telephone | 951-830-0496
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 15164
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License Number State | CA
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