Provider Demographics
NPI:1467415471
Name:MOOSE, THOMAS E (RPA-C)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:E
Last Name:MOOSE
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 CHELSEA WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-3215
Mailing Address - Country:US
Mailing Address - Phone:585-425-3245
Mailing Address - Fax:
Practice Address - Street 1:200 CANAL VIEW BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-2852
Practice Address - Country:US
Practice Address - Phone:585-461-5330
Practice Address - Fax:585-461-9895
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006431363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP10641Medicare UPIN
NYPA0703Medicare ID - Type Unspecified