Basic Information
| Provider Information | |||||||||
| NPI: | 1568403954 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOCKE | ||||||||
| FirstName: | MOIRA | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BANYAGA / CUTHBERTSON | ||||||||
| OtherFirstName: | MOIRA | ||||||||
| OtherMiddleName: | SHAE | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 4528 | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104984891 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 144 SOUTH 'L' ST | ||||||||
| Address2: | |||||||||
| City: | DINUBA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5595916680 | ||||||||
| FaxNumber: | 5595914606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 03/30/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | A101543 | CA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | MD-12646 | HI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | MD-12646 | HI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0804X | A101543 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 00A0251221 | 01 | HI | HMSA BILLING NUMBER | OTHER | 564072-03 | 05 | HI | MEDICAID |