Provider Demographics
NPI:1033379540
Name:MOBERG, KENNETH ALLEN (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:ALLEN
Last Name:MOBERG
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121B WEST 20TH STREET
Mailing Address - Street 2:VILLAGE DIAGNOSTIC & TREATMENT CENTER
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011
Mailing Address - Country:US
Mailing Address - Phone:212-337-9290
Mailing Address - Fax:212-337-9275
Practice Address - Street 1:121B WEST 20TH STREET
Practice Address - Street 2:VILLAGE DIAGNOSTIC & TREATMENT CENTER
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011
Practice Address - Country:US
Practice Address - Phone:212-337-9290
Practice Address - Fax:212-337-9275
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-10
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF302611-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03084613Medicaid