Basic Information
| Provider Information | |||||||||
| NPI: | 1740308501 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOON | ||||||||
| FirstName: | SONG | ||||||||
| MiddleName: | YONG | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8908 LEE MANOR DR | ||||||||
| Address2: | |||||||||
| City: | ELLICOTT CITY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210437999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4435455157 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 UPPER CHESAPEAKE DR | ||||||||
| Address2: | |||||||||
| City: | BEL AIR | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210144324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4436432000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 02/13/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | C0003238 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.