Provider Demographics
NPI:1821010281
Name:MOON, ELLEN (NP)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:J
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:300 PASTEUR DR
Mailing Address - Street 2:
Mailing Address - City:STANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:94305-2200
Mailing Address - Country:US
Mailing Address - Phone:650-723-4000
Mailing Address - Fax:
Practice Address - Street 1:300 PASTEUR DR
Practice Address - Street 2:
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305-2200
Practice Address - Country:US
Practice Address - Phone:650-723-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95024889363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDOH38DBOtherCAREFIRST MARYLAND
DC020353D28OtherINDIVIDUAL MEDICARE NUMBU
DC3696OtherCAREFIRST DC
MD648871400Medicaid
MD543MP075OtherMEDICARE INDIVIDUAL PROV#
MDOH38DBOtherCAREFIRST MARYLAND
MD648871400Medicaid