Provider Demographics
NPI:1518550391
Name:MOSERAY, MOYATU
Entity Type:Individual
Prefix:
First Name:MOYATU
Middle Name:
Last Name:MOSERAY
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 1:3517 PINEY WOODS PL
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20724-5985
Mailing Address - Country:US
Mailing Address - Phone:703-520-4168
Mailing Address - Fax:
Practice Address - Street 1:3517 PINEY WOODS PL
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20724-5985
Practice Address - Country:US
Practice Address - Phone:703-520-4168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-12
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDT24185183700000X
VA2635172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No183700000XPharmacy Service ProvidersPharmacy Technician