Provider Demographics
NPI:1609372481
Name:MOON, AMY
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 CROOKED CREEK PKWY STE 110
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-8507
Mailing Address - Country:US
Mailing Address - Phone:919-620-3333
Mailing Address - Fax:
Practice Address - Street 1:234 CROOKED CREEK PWKY
Practice Address - Street 2:STE 110
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-8507
Practice Address - Country:US
Practice Address - Phone:919-620-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2021-01310208000000X
390200000X
NC202101310208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program