Provider Demographics
NPI:1154818953
Name:MOALLIN, HERSI CABDI
Entity Type:Individual
Prefix:DR
First Name:HERSI
Middle Name:CABDI
Last Name:MOALLIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:HERSI
Other - Middle Name:CABDI
Other - Last Name:MOALLIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 19070
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-9070
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:
Practice Address - Street 1:1860 SHAWANO AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-2667
Practice Address - Country:US
Practice Address - Phone:920-496-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI75622-20207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program