Provider Demographics
NPI:1225203128
Name:MOORE, CORINNE LENORE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CORINNE
Middle Name:LENORE
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:PO BOX 932163
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0001
Mailing Address - Country:US
Mailing Address - Phone:586-412-4000
Mailing Address - Fax:586-412-4100
Practice Address - Street 1:1 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3403
Practice Address - Country:US
Practice Address - Phone:859-301-2160
Practice Address - Fax:859-301-3932
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1096363AM0700X, 174400000X
KYPA1096363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00920661OtherRRMC
KY7100056830Medicaid
KY7100056830Medicaid
KYP400027368Medicare PIN