Provider Demographics
NPI:1023587839
Name:MOON, MITHRA (PA)
Entity type:Individual
Prefix:
First Name:MITHRA
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:
Other - Last Name:GOVIND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1600 VINE ST APT 543
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90028-8825
Mailing Address - Country:US
Mailing Address - Phone:240-778-8493
Mailing Address - Fax:
Practice Address - Street 1:1600 VINE ST APT 543
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90028-8825
Practice Address - Country:US
Practice Address - Phone:240-778-8493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-21
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56157363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant