Basic Information
| Provider Information | |||||||||
| NPI: | 1164434494 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOAN | ||||||||
| FirstName: | AMY | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1289 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336011289 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138447000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 601 7TH ST S STE 510 | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337014736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278286330 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 06/05/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9101907 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 291237600 | 05 | FL | MEDICAID |