Provider Demographics
NPI:1083988091
Name:SERGEJEV, MOIRA ANNETTE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MOIRA
Middle Name:ANNETTE
Last Name:SERGEJEV
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 E ORMAN AVE
Mailing Address - Street 2:SUITE 440
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-3537
Mailing Address - Country:US
Mailing Address - Phone:719-557-4744
Mailing Address - Fax:
Practice Address - Street 1:1925 E ORMAN AVE
Practice Address - Street 2:SUITE 440
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3537
Practice Address - Country:US
Practice Address - Phone:719-557-4744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO990341363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily