Provider Demographics
NPI:1215917976
Name:MOON, MADGE EVANS (CRNA)
Entity type:Individual
Prefix:
First Name:MADGE
Middle Name:EVANS
Last Name:MOON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MADGE
Other - Middle Name:ELVERA
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 105048
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30348-5048
Mailing Address - Country:US
Mailing Address - Phone:770-751-2623
Mailing Address - Fax:770-751-2609
Practice Address - Street 1:3000 HOSPITAL BLVD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4915
Practice Address - Country:US
Practice Address - Phone:770-751-2623
Practice Address - Fax:770-751-2627
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN153489367500000X
SCAPN1305367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000924712DMedicaid
GA000924712EMedicaid
GA000924712DMedicaid
S94663Medicare UPIN