Provider Demographics
NPI:1437194693
Name:MOISESHYN, MAI (PA)
Entity Type:Individual
Prefix:
First Name:MAI
Middle Name:
Last Name:MOISESHYN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MAI
Other - Middle Name:
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3400 W BALL RD
Mailing Address - Street 2:STE 207
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-3737
Mailing Address - Country:US
Mailing Address - Phone:714-826-7440
Mailing Address - Fax:
Practice Address - Street 1:12665 GARDEN GROVE BLVD
Practice Address - Street 2:#502-A
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-1901
Practice Address - Country:US
Practice Address - Phone:714-537-7800
Practice Address - Fax:714-537-7633
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17051363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ03132Medicare UPIN
CAWPA17051DMedicare PIN