Provider Demographics
NPI:1275087439
Name:MOON, MONICA LANCASTER (PA-C)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:LANCASTER
Last Name:MOON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MONICA
Other - Middle Name:A
Other - Last Name:LANCASTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:204 N WESTOVER BLVD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-2983
Mailing Address - Country:US
Mailing Address - Phone:229-888-6559
Mailing Address - Fax:229-436-4107
Practice Address - Street 1:1212 E UNION ST
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:GA
Practice Address - Zip Code:31092-7545
Practice Address - Country:US
Practice Address - Phone:229-268-8865
Practice Address - Fax:229-268-8864
Is Sole Proprietor?:No
Enumeration Date:2016-08-05
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008049363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant