Provider Demographics
NPI:1568755692
Name:MOON, MERRIE TANYA (PA)
Entity Type:Individual
Prefix:MRS
First Name:MERRIE
Middle Name:TANYA
Last Name:MOON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2915 SANDTOWN PLACE CT SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-7537
Mailing Address - Country:US
Mailing Address - Phone:678-360-3504
Mailing Address - Fax:
Practice Address - Street 1:1810 WHITE CIR
Practice Address - Street 2:SUITE 155
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-5835
Practice Address - Country:US
Practice Address - Phone:877-613-1990
Practice Address - Fax:877-613-1990
Is Sole Proprietor?:No
Enumeration Date:2011-05-23
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA5794363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical