Provider Demographics
NPI:1164434494
Name:MOAN, AMY (PA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:MOAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1289
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33601-1289
Mailing Address - Country:US
Mailing Address - Phone:813-844-7000
Mailing Address - Fax:
Practice Address - Street 1:601 7TH ST S STE 510
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4736
Practice Address - Country:US
Practice Address - Phone:727-828-6330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101907363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291237600Medicaid
FLP53776Medicare UPIN
FLE7091ZMedicare ID - Type Unspecified