Provider Demographics
NPI:1730306408
Name:MOMENT, EBONIQUE (MD)
Entity Type:Individual
Prefix:
First Name:EBONIQUE
Middle Name:
Last Name:MOMENT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:EBONIQUE
Other - Middle Name:FARRAH
Other - Last Name:BROWN WOODS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:927 EAST BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203
Mailing Address - Country:US
Mailing Address - Phone:704-377-3389
Mailing Address - Fax:
Practice Address - Street 1:1000 BLYTHE BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5812
Practice Address - Country:US
Practice Address - Phone:704-377-3389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD35024207L00000X
NC2012-01406207L00000X
GA002293207LP3000X
GA84641207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology