Provider Demographics
NPI:1417937194
Name:MOORES, KELLY L (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:L
Last Name:MOORES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1324 LAKELAND HILLS BLVD
Mailing Address - Street 2:ATTN: MANAGED CARE DEPT
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-4543
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3030 HARDEN BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-7952
Practice Address - Country:US
Practice Address - Phone:863-687-1250
Practice Address - Fax:863-687-1258
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290597300Medicaid
FL1497748743OtherGROUP NPI NUMBER /LRHSI
FLDA5786OtherRAILROAD MEDICARE GROUP NUMBER
FLE3318YMedicare PIN
FLS93547Medicare UPIN