Provider Demographics
NPI:1932485489
Name:CARMONA MOSES, SHANNON K (NP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:K
Last Name:CARMONA MOSES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 W WISCONSIN AVE # MS 958
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-7615
Mailing Address - Fax:
Practice Address - Street 1:4855 S MOORLAND RD FL 3
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-7494
Practice Address - Country:US
Practice Address - Phone:262-432-7599
Practice Address - Fax:262-432-7694
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-28
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4680-33363LA2200X
WI4680-033363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1932485489Medicaid