Provider Demographics
NPI:1669891974
Name:MOON, ERIC TYSON (CRNA)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:TYSON
Last Name:MOON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1735 27TH STREET
Mailing Address - Street 2:WALLER BLDG SUITE B06
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-0000
Mailing Address - Country:US
Mailing Address - Phone:740-356-8034
Mailing Address - Fax:740-353-7900
Practice Address - Street 1:1805 27TH ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-2640
Practice Address - Country:US
Practice Address - Phone:740-356-8034
Practice Address - Fax:740-353-7900
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN593747163W00000X, 367500000X
OHRN.312401163W00000X
FLARNP9266653363L00000X
FL101896367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner