Provider Demographics
NPI:1063780484
Name:MOON, MARY TAGISH
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:TAGISH
Last Name:MOON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1123 3RD ST SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-4134
Mailing Address - Country:US
Mailing Address - Phone:505-238-9945
Mailing Address - Fax:
Practice Address - Street 1:1123 3RD ST SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-4134
Practice Address - Country:US
Practice Address - Phone:505-238-9945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula