Provider Demographics
NPI:1407469265
Name:MOON, RANDALL (FNP-C)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:MOON
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1890
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:TX
Mailing Address - Zip Code:78629-1390
Mailing Address - Country:US
Mailing Address - Phone:830-672-6511
Mailing Address - Fax:
Practice Address - Street 1:2060 S COLORADO ST
Practice Address - Street 2:
Practice Address - City:LOCKHART
Practice Address - State:TX
Practice Address - Zip Code:78644-3951
Practice Address - Country:US
Practice Address - Phone:830-494-4001
Practice Address - Fax:877-599-5676
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-30
Last Update Date:2025-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1011256363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily