Provider Demographics
NPI:1205498250
Name:MOISE, NIKENSTON (PA)
Entity type:Individual
Prefix:
First Name:NIKENSTON
Middle Name:
Last Name:MOISE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3890 TURTLE CREEK DR STE C
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-9352
Mailing Address - Country:US
Mailing Address - Phone:386-756-4400
Mailing Address - Fax:
Practice Address - Street 1:3890 TURTLE CREEK DR STE C
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-9352
Practice Address - Country:US
Practice Address - Phone:386-756-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-30
Last Update Date:2019-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR000234-PA207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine