Provider Demographics
NPI:1437685898
Name:MOORE, JERRICA CHAMBERS (PA-C)
Entity Type:Individual
Prefix:
First Name:JERRICA
Middle Name:CHAMBERS
Last Name:MOORE
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:PO BOX 1289
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33601-1289
Mailing Address - Country:US
Mailing Address - Phone:813-844-4800
Mailing Address - Fax:813-844-1103
Practice Address - Street 1:10909 W LINEBAUGH AVE STE 101
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-1741
Practice Address - Country:US
Practice Address - Phone:813-844-4800
Practice Address - Fax:813-844-1103
Is Sole Proprietor?:No
Enumeration Date:2017-05-04
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1262363A00000X
FLPA9116884363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3109599Medicaid
NH1262OtherSTATE LICENSE