Provider Demographics
NPI:1548772809
Name:MOON, GILLIAN D (FNP)
Entity Type:Individual
Prefix:
First Name:GILLIAN
Middle Name:D
Last Name:MOON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5717 PACIFIC CENTER BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-4250
Mailing Address - Country:US
Mailing Address - Phone:858-859-1177
Mailing Address - Fax:
Practice Address - Street 1:5717 PACIFIC CENTER BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-4250
Practice Address - Country:US
Practice Address - Phone:858-859-1188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-26
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANPF95007537363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner