Provider Demographics
NPI:1508600917
Name:MOON, GREG TIMOTHY (PTA)
Entity type:Individual
Prefix:
First Name:GREG
Middle Name:TIMOTHY
Last Name:MOON
Suffix:
Gender:M
Credentials:PTA
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 12883
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28405-0132
Mailing Address - Country:US
Mailing Address - Phone:239-896-7323
Mailing Address - Fax:
Practice Address - Street 1:5725 CAROLINA BEACH RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-2611
Practice Address - Country:US
Practice Address - Phone:910-792-1455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA8363225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant