Provider Demographics
NPI:1467466268
Name:MOORE, LAURA ANN (RPA-C)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:ANN
Last Name:MOORE
Suffix:
Gender:F
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 1:3669 COUNTRYSIDE LN
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:NY
Mailing Address - Zip Code:14505-9781
Mailing Address - Country:US
Mailing Address - Phone:315-926-7733
Mailing Address - Fax:315-926-0731
Practice Address - Street 1:3669 COUNTRYSIDE LN
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:NY
Practice Address - Zip Code:14505-9781
Practice Address - Country:US
Practice Address - Phone:315-926-7733
Practice Address - Fax:315-926-0731
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003362 1207Q00000X
NY3362363AM0700X
NY003362363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP019003362OtherBLUE CHOICE
NYPA0030OtherPREFERRED CARE
NY01293301Medicaid
R55005Medicare UPIN
NYBB8614Medicare PIN