Provider Demographics
NPI:1275262834
Name:MOORE, MALORIE KATHRYN (PA-C)
Entity Type:Individual
Prefix:
First Name:MALORIE
Middle Name:KATHRYN
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 1:4801 W 81ST ST STE 112
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55437-1111
Mailing Address - Country:US
Mailing Address - Phone:952-345-3000
Mailing Address - Fax:
Practice Address - Street 1:4801 W 81ST ST STE 112
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55437-1111
Practice Address - Country:US
Practice Address - Phone:952-345-3000
Practice Address - Fax:952-345-6789
Is Sole Proprietor?:No
Enumeration Date:2022-06-08
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN14373363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant