Provider Demographics
NPI:1104334275
Name:MOON, MARCUS ANTWONE
Entity type:Individual
Prefix:
First Name:MARCUS
Middle Name:ANTWONE
Last Name:MOON
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 1:1825 PARKER RD SE APT 105
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-2644
Mailing Address - Country:US
Mailing Address - Phone:404-547-9678
Mailing Address - Fax:
Practice Address - Street 1:1825 PARKER RD SE APT 105
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-2644
Practice Address - Country:US
Practice Address - Phone:404-547-9678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-11
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0073302279P3900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2279P3900XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredNeonatal/Pediatrics