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General NPI Number Information
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NPI Number | 1952730970
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Entity Type | Individual
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Provider Name | SHONTAE MOODY PA
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Gender | Female
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Dates
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Enumeration Date | 11/12/2013
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Last Update Date | 12/20/2024
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Provider Practice Location Address
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Address Line | 979 N BLACK HORSE PIKE
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City | WILLIAMSTOWN
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State | NJ
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Zip | 08094-1044
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Country | US
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Telephone | 856-629-5151
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Fax |
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Provider Business Mailing Address
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Address Line | 401 ROUTE 73 N BLDG 10, SUITE 320
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City | MARLTON
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State | NJ
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Zip | 08053
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Country | US
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Telephone | 856-872-7055
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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 | MA056299
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 25MP00385300
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License Number State | NJ
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