Provider Demographics
NPI:1225039837
Name:MOORE, MICHAEL ALLEN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ALLEN
Last Name:MOORE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:1925 BRETON RD SE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-4810
Mailing Address - Country:US
Mailing Address - Phone:616-252-1600
Mailing Address - Fax:616-252-1666
Practice Address - Street 1:4200 DIVISION AVE N
Practice Address - Street 2:
Practice Address - City:COMSTOCK PARK
Practice Address - State:MI
Practice Address - Zip Code:49321-9546
Practice Address - Country:US
Practice Address - Phone:616-252-1600
Practice Address - Fax:616-252-1666
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2012-05-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5601002580363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical