Provider Demographics
NPI:1336699800
Name:MOORE, PATRICIA (NP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 ACACIA CT
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22405-2131
Mailing Address - Country:US
Mailing Address - Phone:540-226-9935
Mailing Address - Fax:
Practice Address - Street 1:1101 SAM PERRY BLVD STE 307
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-4466
Practice Address - Country:US
Practice Address - Phone:540-374-3277
Practice Address - Fax:540-374-3280
Is Sole Proprietor?:No
Enumeration Date:2016-10-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001137010163WH1000X
VA0024174222363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163WH1000XNursing Service ProvidersRegistered NurseHospice
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1336699800Medicaid