Provider Demographics
NPI:1619332152
Name:MOODY, CANDACE JACKSON (PA-C)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:JACKSON
Last Name:MOODY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:932 MORREENE RD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-4410
Mailing Address - Country:US
Mailing Address - Phone:919-668-7600
Mailing Address - Fax:
Practice Address - Street 1:932 MORREENE RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-4410
Practice Address - Country:US
Practice Address - Phone:919-668-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-29
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCR226AMedicare PIN