Provider Demographics
NPI:1124691712
Name:MOE, MCKENNA ELYSE (PAC)
Entity type:Individual
Prefix:MISS
First Name:MCKENNA
Middle Name:ELYSE
Last Name:MOE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
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Mailing Address - Street 1:1955 TEXTILE WAY STE B
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-2543
Mailing Address - Country:US
Mailing Address - Phone:678-987-1499
Mailing Address - Fax:678-987-1498
Practice Address - Street 1:1955 TEXTILE WAY STE B
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2543
Practice Address - Country:US
Practice Address - Phone:678-987-1499
Practice Address - Fax:678-987-1498
Is Sole Proprietor?:No
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA10350363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant