Provider Demographics
NPI:1235408196
Name:MOONIN, BRANDON
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:
Last Name:MOONIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5530 MAIN ST.
Mailing Address - Street 2:P.O. BOX 5530
Mailing Address - City:PORT GRAHAM
Mailing Address - State:AK
Mailing Address - Zip Code:99603-5530
Mailing Address - Country:US
Mailing Address - Phone:907-284-2241
Mailing Address - Fax:907-284-2277
Practice Address - Street 1:5530 MAIN ST.
Practice Address - Street 2:
Practice Address - City:PORT GRAHAM
Practice Address - State:AK
Practice Address - Zip Code:99603-5530
Practice Address - Country:US
Practice Address - Phone:907-284-2241
Practice Address - Fax:907-284-2277
Is Sole Proprietor?:No
Enumeration Date:2011-12-22
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker