Provider Demographics
NPI:1356082390
Name:MOORE, STEPHANIE T (PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:T
Last Name:MOORE
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:1221 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2701
Mailing Address - Country:US
Mailing Address - Phone:859-258-6200
Mailing Address - Fax:859-258-6203
Practice Address - Street 1:110 VILLAGE PKWY
Practice Address - Street 2:
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-2327
Practice Address - Country:US
Practice Address - Phone:859-887-8400
Practice Address - Fax:859-885-8448
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2023-01-03
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Provider Licenses
StateLicense IDTaxonomies
KYPA3105363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant