Provider Demographics
NPI:1447764907
Name:MOORE, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 NEW ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1417
Mailing Address - Country:US
Mailing Address - Phone:304-918-4818
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CTR. DRIVE
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301
Practice Address - Country:US
Practice Address - Phone:304-623-3461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-20
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAPRN76344-FNP-BC363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAPRN76344-FNP-BCOtherWV FNP-BC LICENSE NUMBER