Provider Demographics
NPI:1699723361
Name:MOORE, PAULA A (CNM)
Entity type:Individual
Prefix:
First Name:PAULA
Middle Name:A
Last Name:MOORE
Suffix:
Gender:M
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 GRAND AVENUE
Mailing Address - Street 2:UNITED HEALTH SERVICES HOSPITAL INC
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790
Mailing Address - Country:US
Mailing Address - Phone:607-770-0025
Mailing Address - Fax:607-729-3982
Practice Address - Street 1:33-57 HARRISON ST
Practice Address - Street 2:UNITED HEALTH SERVICES HOSPITALS INC
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790
Practice Address - Country:US
Practice Address - Phone:607-763-6101
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000479367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02152656Medicaid
NYCC5326Medicare ID - Type Unspecified
NY02152656Medicaid