Provider Demographics
NPI:1467112250
Name:MOORE, JOHNATHAN M (PA)
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:M
Last Name:MOORE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:325 N JAMES ST APT 2
Mailing Address - Street 2:
Mailing Address - City:PEEKSKILL
Mailing Address - State:NY
Mailing Address - Zip Code:10566-2486
Mailing Address - Country:US
Mailing Address - Phone:401-300-7652
Mailing Address - Fax:
Practice Address - Street 1:55 GREEN HOLLOW RD
Practice Address - Street 2:
Practice Address - City:DANIELSON
Practice Address - State:CT
Practice Address - Zip Code:06239-3533
Practice Address - Country:US
Practice Address - Phone:860-779-1865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-21
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty