Provider Demographics
NPI:1275295164
Name:L KATHERINE MOON
Entity Type:Organization
Organization Name:L KATHERINE MOON
Other - Org Name:FISHERS LANDING PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:L KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:360-816-0277
Mailing Address - Street 1:6715 NE 63RD ST STE 436
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-1980
Mailing Address - Country:US
Mailing Address - Phone:360-816-0277
Mailing Address - Fax:360-567-4004
Practice Address - Street 1:406 SE 131ST AVE STE C
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-4004
Practice Address - Country:US
Practice Address - Phone:360-816-0277
Practice Address - Fax:360-567-4004
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:L KATHERINE MOON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-10-08
Last Update Date:2022-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty