Provider Demographics
NPI:1497162994
Name:MOORE, TRENTON K (MMSC, PA-C, MS, ATC)
Entity Type:Individual
Prefix:
First Name:TRENTON
Middle Name:K
Last Name:MOORE
Suffix:
Gender:M
Credentials:MMSC, PA-C, MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1829 LAWRENCEVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-5728
Mailing Address - Country:US
Mailing Address - Phone:404-292-8335
Mailing Address - Fax:
Practice Address - Street 1:1829 LAWRENCEVILLE HWY
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5728
Practice Address - Country:US
Practice Address - Phone:404-292-8335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-16
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 35332255A2300X
GA10266363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program