Provider Demographics
NPI:1225412067
Name:MOISAN, AMANDA (DPT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MOISAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 N A ST
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79705-5304
Mailing Address - Country:US
Mailing Address - Phone:432-618-9952
Mailing Address - Fax:432-618-9953
Practice Address - Street 1:3003 N A ST
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79705-5304
Practice Address - Country:US
Practice Address - Phone:432-618-9952
Practice Address - Fax:432-618-9953
Is Sole Proprietor?:No
Enumeration Date:2015-07-10
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1259189225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist