Provider Demographics
NPI:1316902679
Name:MOORE, RONALD JASON (PA-C)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:JASON
Last Name:MOORE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3310 WATERMAN WAY
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-5250
Mailing Address - Country:US
Mailing Address - Phone:352-343-1216
Mailing Address - Fax:352-343-1582
Practice Address - Street 1:3310 WATERMAN WAY
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-5250
Practice Address - Country:US
Practice Address - Phone:352-343-1216
Practice Address - Fax:352-343-1582
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102945363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00414081OtherRR MEDICARE
FLY04L4OtherBCBS OF FL
FL292533800Medicaid
FLU4075OtherBCBS
FLP00702090OtherRR MEDICARE
FLU4075LMedicare PIN
FLU4075OtherBCBS
FLY04L4OtherBCBS OF FL
FL292533800Medicaid
FLP00702090OtherRR MEDICARE
FLU4075RMedicare PIN
FLU4075UMedicare PIN
FLU4075WMedicare PIN
FLU4075Medicare PIN