Provider Demographics
NPI:1346514692
Name:MOORE, BRADLEY J (PA)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:J
Last Name:MOORE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 ACCELERATOR WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-3078
Mailing Address - Country:US
Mailing Address - Phone:865-546-2663
Mailing Address - Fax:865-546-9047
Practice Address - Street 1:1600 ACCELERATOR WAY STE 200
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-3078
Practice Address - Country:US
Practice Address - Phone:865-546-2663
Practice Address - Fax:865-546-9047
Is Sole Proprietor?:No
Enumeration Date:2012-03-05
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2115363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4323294OtherBLUECROSS BLUESHIELD
TN4328037OtherBLUECROSS BLUESHIELD - PA AT SURGERY
TNP01243057OtherRAILROAD MEDICARE
TN1528209Medicaid
TN103I976539Medicare PIN
TN4323294OtherBLUECROSS BLUESHIELD