Provider Demographics
NPI:1003195355
Name:MOORE, PATRICIA M (MD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:M
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-637-1779
Mailing Address - Fax:704-637-1121
Practice Address - Street 1:1910 JAKE ALEXANDER BLVD W STE 102
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28147
Practice Address - Country:US
Practice Address - Phone:704-637-1779
Practice Address - Fax:704-637-1121
Is Sole Proprietor?:No
Enumeration Date:2011-08-04
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC220192084N0400X
PAMD066685L2084N0400X
VA01012528792084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1830438Medicaid
VA1830438Medicaid
B48657Medicare UPIN