Provider Demographics
NPI:1366630519
Name:MCMOON, PATRICE (PA-C)
Entity type:Individual
Prefix:
First Name:PATRICE
Middle Name:
Last Name:MCMOON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 DEL MONTE AVE STE B
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-2401
Mailing Address - Country:US
Mailing Address - Phone:831-622-6930
Mailing Address - Fax:
Practice Address - Street 1:2020 DEL MONTE AVE STE B
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-2401
Practice Address - Country:US
Practice Address - Phone:831-622-6930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110009009207R00000X, 363A00000X
COPA0003501363AM0700X
COPA.0003501363AM0700X
CA57069363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1366630519Medicaid
1366630519OtherNPI
NV1366630519Medicaid
NVCX726XMedicare PIN