Provider Demographics
NPI:1356625883
Name:MOON, ANDREW JONATHAN (LMP)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:JONATHAN
Last Name:MOON
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 W BLUFF DR
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-9545
Mailing Address - Country:US
Mailing Address - Phone:360-477-9235
Mailing Address - Fax:
Practice Address - Street 1:603 E 8TH ST
Practice Address - Street 2:SUITE D
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-6251
Practice Address - Country:US
Practice Address - Phone:360-452-2934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-03
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60238191225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist