Provider Demographics
NPI:1417126145
Name:MOORE, JOHN R (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
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 1:1421 S POTOMAC ST STE 330
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80012-4512
Mailing Address - Country:US
Mailing Address - Phone:303-953-2920
Mailing Address - Fax:303-997-5225
Practice Address - Street 1:1421 S POTOMAC ST STE 330
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-4512
Practice Address - Country:US
Practice Address - Phone:303-953-2920
Practice Address - Fax:303-997-5225
Is Sole Proprietor?:No
Enumeration Date:2008-02-27
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05601363A00000X
COPA.0002778363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8Y3865OtherBCBS
TX8K5271Medicare PIN
TX8L15024Medicare PIN