Provider Demographics
NPI:1124406178
Name:MOORE, NATHANIEL P (PA)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:P
Last Name:MOORE
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Gender:M
Credentials:PA
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Mailing Address - Street 1:111 COLCHESTER AVE.
Mailing Address - Street 2:UVM MEDICAL CENTER - SURGERY/EMERGENCY DEPT.
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-1473
Mailing Address - Country:US
Mailing Address - Phone:802-847-2434
Mailing Address - Fax:802-847-4802
Practice Address - Street 1:111 COLCHESTER AVE.
Practice Address - Street 2:UVM MEDICAL CENTER - SURGERY/EMERGENCY DEPT.
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-2434
Practice Address - Fax:802-847-4802
Is Sole Proprietor?:No
Enumeration Date:2015-05-11
Last Update Date:2015-06-08
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Provider Licenses
StateLicense IDTaxonomies
VT055.0031256363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant