Provider Demographics
NPI:1255077301
Name:MOFFOR, DAVID NDIKUM (DNP, CRNA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:NDIKUM
Last Name:MOFFOR
Suffix:
Gender:M
Credentials:DNP, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25161 HIMALAYAS TER
Mailing Address - Street 2:
Mailing Address - City:ALDIE
Mailing Address - State:VA
Mailing Address - Zip Code:20105-5689
Mailing Address - Country:US
Mailing Address - Phone:571-484-0556
Mailing Address - Fax:
Practice Address - Street 1:3000 COLISEUM DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-5963
Practice Address - Country:US
Practice Address - Phone:757-736-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-11
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001268324163W00000X
VA137560367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered Nurse