Provider Demographics
NPI:1194723155
Name:MOAT, MARY ELIZABETH (RN, NP)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELIZABETH
Last Name:MOAT
Suffix:
Gender:F
Credentials:RN, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1841 W HALSEY AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-2842
Mailing Address - Country:US
Mailing Address - Phone:414-281-3896
Mailing Address - Fax:
Practice Address - Street 1:ZABLOCKI VA MEDICAL CENTER
Practice Address - Street 2:5000 W NATIONAL AVE
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53295-0001
Practice Address - Country:US
Practice Address - Phone:414-385-2000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49641363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner