Provider Demographics
NPI:1477641017
Name:MOORE, CATHY SHABAZ (PA-C)
Entity Type:Individual
Prefix:
First Name:CATHY
Middle Name:SHABAZ
Last Name:MOORE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7993 172ND ST W
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-9132
Mailing Address - Country:US
Mailing Address - Phone:763-301-2032
Mailing Address - Fax:
Practice Address - Street 1:9220 JAMES AVE S STE 1
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-4504
Practice Address - Country:US
Practice Address - Phone:952-234-5898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9909363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant