Provider Demographics
NPI:1124286109
Name:MOORE, KEVIN DWAYNE (PTA)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:DWAYNE
Last Name:MOORE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W AQUA AVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-7764
Mailing Address - Country:US
Mailing Address - Phone:208-762-1122
Mailing Address - Fax:
Practice Address - Street 1:500 W AQUA AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-7764
Practice Address - Country:US
Practice Address - Phone:208-762-1122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA344225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant