Provider Demographics
NPI:1831901578
Name:AZCONA, MOISES EMMANUEL
Entity type:Individual
Prefix:
First Name:MOISES
Middle Name:EMMANUEL
Last Name:AZCONA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1524 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSIDE
Mailing Address - State:NJ
Mailing Address - Zip Code:07205-1511
Mailing Address - Country:US
Mailing Address - Phone:908-986-8310
Mailing Address - Fax:
Practice Address - Street 1:111 W UNION AVE
Practice Address - Street 2:
Practice Address - City:BOUND BROOK
Practice Address - State:NJ
Practice Address - Zip Code:08805-1396
Practice Address - Country:US
Practice Address - Phone:908-986-8310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-21
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT003033002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer