Provider Demographics
NPI:1952730970
Name:MOODY, SHONTAE (PA)
Entity type:Individual
Prefix:
First Name:SHONTAE
Middle Name:
Last Name:MOODY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SHONTAE
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:401 ROUTE 73 N BLDG 10, SUITE 320
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053
Mailing Address - Country:US
Mailing Address - Phone:856-872-7055
Mailing Address - Fax:
Practice Address - Street 1:979 N BLACK HORSE PIKE
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08094-1044
Practice Address - Country:US
Practice Address - Phone:856-629-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-12
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056299363A00000X
NJ25MP00385300363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant