Provider Demographics
NPI:1972115582
Name:MOORE, MICHAEL SHANE (LPTA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SHANE
Last Name:MOORE
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2757 VANDY CT
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36110-1339
Mailing Address - Country:US
Mailing Address - Phone:334-669-1430
Mailing Address - Fax:
Practice Address - Street 1:2757 VANDY CT
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36110-1339
Practice Address - Country:US
Practice Address - Phone:334-669-1430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTA9712208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation