Provider Demographics
NPI:1356643324
Name:MOORE, PATRICIA LOUISE (MEDICAID PROVIDER)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:LOUISE
Last Name:MOORE
Suffix:
Gender:F
Credentials:MEDICAID PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 DECAMP DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46226-6040
Mailing Address - Country:US
Mailing Address - Phone:317-410-7339
Mailing Address - Fax:
Practice Address - Street 1:1453 S. BANCROFT
Practice Address - Street 2:
Practice Address - City:INDIANAPLIS
Practice Address - State:IN
Practice Address - Zip Code:46203-3709
Practice Address - Country:US
Practice Address - Phone:317-410-7339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-24
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN200974970A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN304563020AOtherMEDICARE