Basic Information
| Provider Information | |||||||||
| NPI: | 1124691712 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOE | ||||||||
| FirstName: | MCKENNA | ||||||||
| MiddleName: | ELYSE | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1955 TEXTILE WAY STE B | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305012543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6789871499 | ||||||||
| FaxNumber: | 6789871498 | ||||||||
| Practice Location | |||||||||
| Address1: | 1955 TEXTILE WAY STE B | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305012543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6789871499 | ||||||||
| FaxNumber: | 6789871498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2021 | ||||||||
| LastUpdateDate: | 07/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 10350 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.