Provider Demographics
NPI:1093127615
Name:MOORE, ALYSSA N (PA-C)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:N
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 1:4 HAMILTON ST
Mailing Address - Street 2:APT 3
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-2049
Mailing Address - Country:US
Mailing Address - Phone:518-669-2969
Mailing Address - Fax:
Practice Address - Street 1:412 STATE ROUTE 37
Practice Address - Street 2:
Practice Address - City:HOGANSBURG
Practice Address - State:NY
Practice Address - Zip Code:13655-3109
Practice Address - Country:US
Practice Address - Phone:518-358-3141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-02
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP92874363A00000X
NY017600363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant