Provider Demographics
NPI:1578600623
Name:SMITH, MOON E (MSN)
Entity Type:Individual
Prefix:MS
First Name:MOON
Middle Name:E
Last Name:SMITH
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8500-6355
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-0001
Mailing Address - Country:US
Mailing Address - Phone:610-497-7520
Mailing Address - Fax:610-497-7525
Practice Address - Street 1:1560 GARRETT RD
Practice Address - Street 2:
Practice Address - City:UPPER DARBY
Practice Address - State:PA
Practice Address - Zip Code:19082-4505
Practice Address - Country:US
Practice Address - Phone:610-284-3300
Practice Address - Fax:610-284-3706
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMW008272L367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001250948Medicaid