Provider Demographics
NPI:1013023407
Name:MOORE, KENNETH E (PA C)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:E
Last Name:MOORE
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 UNIVERSITY ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-2338
Mailing Address - Country:US
Mailing Address - Phone:509-200-2852
Mailing Address - Fax:
Practice Address - Street 1:1313 N 13TH AVE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-8817
Practice Address - Country:US
Practice Address - Phone:509-200-2852
Practice Address - Fax:509-522-5899
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003031363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1081678Medicaid
WAAB02410Medicare ID - Type Unspecified
WA1081678Medicaid