Provider Demographics
NPI:1568155182
Name:MOON, WILLIAM (NP)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:MOON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3843
Mailing Address - Country:US
Mailing Address - Phone:631-672-2778
Mailing Address - Fax:
Practice Address - Street 1:50 NEW YORK AVE # 25A
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3448
Practice Address - Country:US
Practice Address - Phone:631-862-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-30
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY432542363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care