Provider Demographics
NPI:1114671765
Name:MOORE, ALYSSA K (PA-C)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:K
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 1:9166 PORTER RD
Mailing Address - Street 2:
Mailing Address - City:RYLAND HGHT
Mailing Address - State:KY
Mailing Address - Zip Code:41015-9587
Mailing Address - Country:US
Mailing Address - Phone:513-766-2874
Mailing Address - Fax:
Practice Address - Street 1:10500 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:OH
Practice Address - Zip Code:45242-4402
Practice Address - Country:US
Practice Address - Phone:513-865-5552
Practice Address - Fax:513-865-2227
Is Sole Proprietor?:No
Enumeration Date:2022-02-11
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.0007057363A00000X
OH50.007057RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0462231Medicaid