Basic Information
| Provider Information | |||||||||
| NPI: | 1669891974 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOON | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | TYSON | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1735 27TH STREET | ||||||||
| Address2: | WALLER BLDG SUITE B06 | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456620000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403568034 | ||||||||
| FaxNumber: | 7403537900 | ||||||||
| Practice Location | |||||||||
| Address1: | 1805 27TH ST | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456622640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403568034 | ||||||||
| FaxNumber: | 7403537900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2014 | ||||||||
| LastUpdateDate: | 06/22/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN593747 | PA | N | Nursing Service Providers | Registered Nurse | 163W00000X | RN.312401 | OH | N | Nursing Service Providers | Registered Nurse | 363L00000X | ARNP9266653 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 367500000X | 101896 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | RN593747 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.