Provider Demographics
NPI:1407151756
Name:MOORE, GARY (PTA)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 SW 14TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-4701
Mailing Address - Country:US
Mailing Address - Phone:316-283-4770
Mailing Address - Fax:316-283-5199
Practice Address - Street 1:200 SW 14TH ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:KS
Practice Address - Zip Code:67114-4701
Practice Address - Country:US
Practice Address - Phone:316-283-4770
Practice Address - Fax:316-283-5199
Is Sole Proprietor?:No
Enumeration Date:2011-01-18
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-01561225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant