Provider Demographics
NPI:1255561312
Name:MOON, DANIEL L (CRNP)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:L
Last Name:MOON
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 N 4TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:OAKLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21550-1371
Mailing Address - Country:US
Mailing Address - Phone:301-334-8171
Mailing Address - Fax:301-334-1819
Practice Address - Street 1:311 N 4TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:OAKLAND
Practice Address - State:MD
Practice Address - Zip Code:21550-1371
Practice Address - Country:US
Practice Address - Phone:301-334-8171
Practice Address - Fax:301-334-1819
Is Sole Proprietor?:No
Enumeration Date:2009-07-22
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR114948363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD334403700Medicaid
WV3810017953Medicaid
MD334403700Medicaid