Provider Demographics
NPI:1306846142
Name:MOORE, PAMELA J (CPNP)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:J
Last Name:MOORE
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 PINE ST
Mailing Address - Street 2:
Mailing Address - City:VARNVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29944-0969
Mailing Address - Country:US
Mailing Address - Phone:803-943-5228
Mailing Address - Fax:803-943-4591
Practice Address - Street 1:1000 PINE STREET
Practice Address - Street 2:
Practice Address - City:VARNVILLE
Practice Address - State:SC
Practice Address - Zip Code:29944-0969
Practice Address - Country:US
Practice Address - Phone:803-943-5228
Practice Address - Fax:803-943-4591
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1881363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0365Medicaid
SCRHC013Medicaid
SC570669239OtherFED TIN NUMBER
SC423820Medicare Oscar/Certification
SC4004Medicare PIN