Provider Demographics
NPI:1366630519
Name:MCMOON, PATRICE (PA-C)
Entity Type:Individual
Prefix:
First Name:PATRICE
Middle Name:
Last Name:MCMOON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 S DELAWARE ST STE 130
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-2394
Mailing Address - Country:US
Mailing Address - Phone:650-319-8654
Mailing Address - Fax:650-251-4999
Practice Address - Street 1:3050 S DELAWARE ST STE 130
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-2394
Practice Address - Country:US
Practice Address - Phone:650-319-8654
Practice Address - Fax:650-251-4999
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA0003501363AM0700X
VA0110009009363A00000X, 207R00000X
COPA.0003501363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1366630519OtherNPI
NV1366630519Medicaid
NV1366630519Medicaid
NVCX726XMedicare PIN