Provider Demographics
NPI:1063599710
Name:MOORE, MICHELE L (NP)
Entity type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:L
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1144 MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:ONEIDA
Mailing Address - State:NY
Mailing Address - Zip Code:13421-2726
Mailing Address - Country:US
Mailing Address - Phone:315-363-9380
Mailing Address - Fax:315-363-9382
Practice Address - Street 1:1144 MEADOW DR
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421-2726
Practice Address - Country:US
Practice Address - Phone:315-363-9380
Practice Address - Fax:315-363-9382
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF300032363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02011301Medicaid
161355152OtherBCBS
350496OtherMVP
161355152OtherBCBS