Provider Demographics
NPI:1508349200
Name:MOA, MELISSA A
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:MOA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4910 LORD RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78220-3536
Mailing Address - Country:US
Mailing Address - Phone:210-471-1504
Mailing Address - Fax:
Practice Address - Street 1:4211 GARDENDALE ST STE A201
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3180
Practice Address - Country:US
Practice Address - Phone:210-614-4434
Practice Address - Fax:210-614-4407
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35849251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX35849OtherTX BOARD OF EXAMINERS