Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | 39233 | SC |
Y | 2080P0204X | Pediatric Emergency Doctor | 39233 | SC |
NPI | 1073958120 |
---|---|
Provider Name | Mr. Matthew Morgan Moake |
First Address | Charlotte, NC 28275-1461 |
Second Address | Charleston, SC 29425-2106 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/05/2013 |
Last Update Date | 14/12/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
39233 | SC LLR (01) | SC |