Provider Demographics
NPI:1427003524
Name:MOORE, DAVID WENDELL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:WENDELL
Last Name:MOORE
Suffix:
Gender:M
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:PO BOX 21890
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4115
Mailing Address - Country:US
Mailing Address - Phone:502-907-0356
Mailing Address - Fax:502-919-9780
Practice Address - Street 1:101 PROSPEROUS PL STE 300
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1836
Practice Address - Country:US
Practice Address - Phone:859-275-5229
Practice Address - Fax:859-977-2683
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA347363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300009771Medicaid
KY611369666OtherHUMANA PIN
KY000000299029OtherANTHEM PIN
11368446OtherCAQH PROVIDER ID
CS1801900158OtherCARESOURCE ID
KY164291500OtherDEPARTMENT OF LABOR
KY84555KYIPOtherAETNA BETTER HEALTH OF KY PROVIDER ID NUMBER
KY1468559OtherWELLCARE OF KY PROVIDER ID NUMBER
KY95003471Medicaid
7085548OtherAETNA PIN