Provider Demographics
NPI:1467560631
Name:MOORE, RICHARD BRUCE (PA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:BRUCE
Last Name:MOORE
Suffix:
Gender:M
Credentials:PA
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 70
Mailing Address - Street 2:
Mailing Address - City:BULLS GAP
Mailing Address - State:TN
Mailing Address - Zip Code:37711-0070
Mailing Address - Country:US
Mailing Address - Phone:423-235-0063
Mailing Address - Fax:
Practice Address - Street 1:1907 W MORRIS BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37813-3860
Practice Address - Country:US
Practice Address - Phone:423-587-2707
Practice Address - Fax:423-587-3224
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA0000001279363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3664238Medicare ID - Type Unspecified
TNS81904Medicare UPIN