Provider Demographics
NPI:1184192791
Name:MOORE, RACHAEL ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:RACHAEL
Middle Name:ANN
Last Name:MOORE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:RACHAEL
Other - Middle Name:
Other - Last Name:JASINOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3489 LEXINGTON RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-1402
Mailing Address - Country:US
Mailing Address - Phone:517-614-6836
Mailing Address - Fax:
Practice Address - Street 1:3003 S BALDWIN RD STE B
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48359-2358
Practice Address - Country:US
Practice Address - Phone:248-301-1090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-13
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009555363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant