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General NPI Number Information
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NPI Number | 1366316259
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Entity Type | Individual
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Provider Name | ETHAN JUNO MOON
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Gender | Male
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Dates
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Enumeration Date | 10/02/2025
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Last Update Date | 10/02/2025
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Provider Practice Location Address
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Address Line | 11140 ROCKVILLE PIKE STE 100
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City | ROCKVILLE
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State | MD
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Zip | 20852-3149
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Country | US
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Telephone | 240-575-6210
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Fax | 240-877-0511
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Provider Business Mailing Address
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Address Line | 354 SOUTHWOOD DR
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City | OXFORD
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State | AL
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Zip | 36203-5020
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Country | US
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Telephone | 240-575-6210
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Fax | 240-877-0511
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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 | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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