Provider Demographics
NPI:1992363329
Name:MOORE, RAQUEL
Entity type:Individual
Prefix:
First Name:RAQUEL
Middle Name:
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 1:3896 BEVERLY AVE NE STE 40
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-1374
Mailing Address - Country:US
Mailing Address - Phone:503-588-0076
Mailing Address - Fax:503-588-7578
Practice Address - Street 1:3896 BEVERLY AVE NE STE 40
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1374
Practice Address - Country:US
Practice Address - Phone:503-588-0076
Practice Address - Fax:503-588-7578
Is Sole Proprietor?:No
Enumeration Date:2019-05-31
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA202068363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant