Provider Demographics
NPI:1447820527
Name:MOUA, PEDA B (DC)
Entity type:Individual
Prefix:DR
First Name:PEDA
Middle Name:B
Last Name:MOUA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2763 S ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5325
Mailing Address - Country:US
Mailing Address - Phone:920-884-2488
Mailing Address - Fax:920-884-2470
Practice Address - Street 1:2763 S ONEIDA ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5325
Practice Address - Country:US
Practice Address - Phone:920-884-2488
Practice Address - Fax:920-884-2470
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5572111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty