Provider Demographics
NPI:1104946383
Name:MOON, TINA LEE (PA-C)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:LEE
Last Name:MOON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:WAUTHENA
Other - Middle Name:LEE
Other - Last Name:GARY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:7809 HEMLOCK AVE
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-4119
Mailing Address - Country:US
Mailing Address - Phone:951-830-0496
Mailing Address - Fax:
Practice Address - Street 1:1334 W COVINA BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3211
Practice Address - Country:US
Practice Address - Phone:909-599-8677
Practice Address - Fax:909-592-0999
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15164363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant