Provider Demographics
NPI:1104823277
Name:MOORE, JOSEPH (PA)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 POCAHONTAS TRL
Mailing Address - Street 2:
Mailing Address - City:QUINTON
Mailing Address - State:VA
Mailing Address - Zip Code:23141-1657
Mailing Address - Country:US
Mailing Address - Phone:804-932-4388
Mailing Address - Fax:804-966-9860
Practice Address - Street 1:1850 POCAHONTAS TRL
Practice Address - Street 2:
Practice Address - City:QUINTON
Practice Address - State:VA
Practice Address - Zip Code:23141-1657
Practice Address - Country:US
Practice Address - Phone:804-932-4388
Practice Address - Fax:804-932-9860
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840202363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S72513Medicare UPIN
VA970000258Medicare ID - Type Unspecified