Provider Demographics
NPI:1871153098
Name:MOORHEAD, PAYTON
Entity type:Individual
Prefix:
First Name:PAYTON
Middle Name:
Last Name:MOORHEAD
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 1:6000 RANDOLPH BLVD APT 705
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78233-5745
Mailing Address - Country:US
Mailing Address - Phone:210-288-1830
Mailing Address - Fax:
Practice Address - Street 1:2040 BABCOCK RD STE 304
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4428
Practice Address - Country:US
Practice Address - Phone:210-731-9570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX312644164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse