Provider Demographics
NPI:1033389192
Name:MOORE, MARYBETH AUCOIN (PA-C, MPH)
Entity Type:Individual
Prefix:MS
First Name:MARYBETH
Middle Name:AUCOIN
Last Name:MOORE
Suffix:
Gender:F
Credentials:PA-C, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 QUAKER LN S
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06110-1026
Mailing Address - Country:US
Mailing Address - Phone:860-233-5133
Mailing Address - Fax:860-233-5212
Practice Address - Street 1:631 QUAKER LN S
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06110-1026
Practice Address - Country:US
Practice Address - Phone:860-233-5133
Practice Address - Fax:860-233-5212
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002729363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT002729OtherLICENSE