Provider Demographics
NPI:1477888998
Name:MOORE, JULIE L (PA-C)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:L
Last Name:MOORE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:L
Other - Last Name:WORTMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1105 6TH ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2349
Mailing Address - Country:US
Mailing Address - Phone:231-947-0673
Mailing Address - Fax:
Practice Address - Street 1:4624 N SPIDER LAKE RD
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49696-8440
Practice Address - Country:US
Practice Address - Phone:231-947-0673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-16
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601005691OtherLICENSE