Provider Demographics
NPI:1992289698
Name:MOORE, MICHAEL (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:538 S EDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-6133
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1460 G ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-4112
Practice Address - Country:US
Practice Address - Phone:541-726-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant