Provider Demographics
NPI:1922037738
Name:MOY, LANNIE (PA-C)
Entity type:Individual
Prefix:
First Name:LANNIE
Middle Name:
Last Name:MOY
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 1:200 OCEANGATE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4302
Mailing Address - Country:US
Mailing Address - Phone:562-499-6191
Mailing Address - Fax:562-499-6171
Practice Address - Street 1:17500 FOOTHILL BLVD
Practice Address - Street 2:#A-2
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3736
Practice Address - Country:US
Practice Address - Phone:909-428-0171
Practice Address - Fax:877-778-9312
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA10717207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEFF: 2/21/13- S BERNMedicaid
PA107170OtherMEDI CAL
CAPA10717Medicaid
CAEFF:2/21/13 FONTANAMedicaid
CAEFF: 2/21/13 RIALTOMedicaid
CAEFF: 2/21/13- S BERNMedicaid
CAEFF:2/21/13 FONTANAMedicaid
CAWPA10717GMedicare PIN
CAPA10717Medicaid
CAAU048WMedicare PIN
CAWPA10717EMedicare PIN
CA00A0PA107107Medicare PIN
CAWPA10717AMedicare PIN
PA107170OtherMEDI CAL
A64172Medicare UPIN
CAWPA10717CMedicare PIN
CAAU048VMedicare PIN