Provider Demographics
NPI:1710546817
Name:MOODY, SHAWN MICHAEL (CRNP)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:MICHAEL
Last Name:MOODY
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 PINE NUT DR
Mailing Address - Street 2:
Mailing Address - City:EIGHTY FOUR
Mailing Address - State:PA
Mailing Address - Zip Code:15330-2659
Mailing Address - Country:US
Mailing Address - Phone:724-941-2157
Mailing Address - Fax:
Practice Address - Street 1:4800 FRIENDSHIP AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15224-1793
Practice Address - Country:US
Practice Address - Phone:412-578-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP020260363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care