Provider Demographics
NPI:1962067736
Name:MOORE, PHOENIX N
Entity type:Individual
Prefix:
First Name:PHOENIX
Middle Name:N
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 4TH AVE STE 1818
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15222-1716
Mailing Address - Country:US
Mailing Address - Phone:412-407-3729
Mailing Address - Fax:
Practice Address - Street 1:239 4TH AVE STE 1818
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15222-1716
Practice Address - Country:US
Practice Address - Phone:412-407-3729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-07
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA7774100202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebology