Provider Demographics
NPI:1588601108
Name:MOON, THOMAS E (PA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:E
Last Name:MOON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5350 FRANTZ RD
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-4259
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:285 E STATE ST
Practice Address - Street 2:SUITE 260
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-4354
Practice Address - Country:US
Practice Address - Phone:614-566-9035
Practice Address - Fax:614-566-9302
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50000162363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant