Provider Demographics
NPI:1487682290
Name:MOORE, SUSAN KAYE (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:KAYE
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 OMNI BLVD
Mailing Address - Street 2:STE 303
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4477
Mailing Address - Country:US
Mailing Address - Phone:757-232-8769
Mailing Address - Fax:757-232-8875
Practice Address - Street 1:815 GAFFEY PL
Practice Address - Street 2:
Practice Address - City:FORT EUSTIS
Practice Address - State:VA
Practice Address - Zip Code:23604-1505
Practice Address - Country:US
Practice Address - Phone:757-314-7500
Practice Address - Fax:757-878-6280
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166514363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAPENDINGMedicare ID - Type Unspecified
PENDINGMedicare UPIN