MEDICARE: MICHEAL ALLAN MOISANT D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	K7585	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	8F8440	OTHER	TX	BCBS OF TEXAS

General Provider Information

NPI Number	:	1063463800
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHEAL ALLAN MOISANT D.O.

Provider Business Mailing Address
First Line	:	P.O. BOX 961205
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76161-1205
Country	:	US
Telephone Number	:	817-740-8450
Fax Number	:

Provider Business Practice Location Address
First Line	:	4412 KELL WEST BLVD
Second Line	:
City	:	WICHITA FALLS
State	:	TX
Zip	:	76309-4719
Country	:	US
Telephone Number	:	940-696-0011
Fax Number	:	940-696-2248

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/15/2006
Last Update Date	:	11/08/2019

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