Provider Demographics
NPI:1033504857
Name:MOORE, ANGELIA RENEE' (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ANGELIA
Middle Name:RENEE'
Last Name:MOORE
Suffix:
Gender:F
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 1:6439 IRON BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23234-5205
Mailing Address - Country:US
Mailing Address - Phone:804-271-8990
Mailing Address - Fax:
Practice Address - Street 1:6439 IRON BRIDGE RD
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23234-5205
Practice Address - Country:US
Practice Address - Phone:804-271-8990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-30
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004893363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical