Provider Demographics
NPI:1306085444
Name:MOFFETT, SHANNON (MD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:MOFFETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 BERGEN ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-2496
Mailing Address - Country:US
Mailing Address - Phone:973-972-5128
Mailing Address - Fax:973-972-6646
Practice Address - Street 1:150 BERGEN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2496
Practice Address - Country:US
Practice Address - Phone:973-972-5128
Practice Address - Fax:973-972-6646
Is Sole Proprietor?:No
Enumeration Date:2009-02-12
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA104212207P00000X
NJ25MA09979800207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine