Provider Demographics
NPI:1982079315
Name:MOON, KERI LEIGH (PA)
Entity type:Individual
Prefix:
First Name:KERI
Middle Name:LEIGH
Last Name:MOON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KERI
Other - Middle Name:LEIGH
Other - Last Name:STUMP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-2111
Mailing Address - Fax:
Practice Address - Street 1:1605 S 31ST ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76508-3483
Practice Address - Country:US
Practice Address - Phone:254-215-0100
Practice Address - Fax:979-776-5624
Is Sole Proprietor?:No
Enumeration Date:2015-12-10
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA10170363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA10170OtherPA LICENSE