Provider Demographics
NPI:1699739813
Name:MOORE, DARYL JOSEPH (PA-C)
Entity type:Individual
Prefix:
First Name:DARYL
Middle Name:JOSEPH
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 1:3953 TAMPA RD STE 101
Mailing Address - Street 2:
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-3233
Mailing Address - Country:US
Mailing Address - Phone:727-464-2867
Mailing Address - Fax:727-464-2663
Practice Address - Street 1:3953 TAMPA RD STE 101
Practice Address - Street 2:
Practice Address - City:OLDSMAR
Practice Address - State:FL
Practice Address - Zip Code:34677-3233
Practice Address - Country:US
Practice Address - Phone:727-464-2867
Practice Address - Fax:727-464-2663
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103678363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00316796OtherRAILROAD MEDICARE
FL2925591 00Medicaid
FL285724874OtherTRICARE
FLP00316796OtherRAILROAD MEDICARE
FLU7250YMedicare PIN
FL2925591 00Medicaid
FLU7250ZMedicare PIN