Provider Demographics
NPI:1497750129
Name:MOORE, NATHAN M (MD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:M
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:991 ROUTE 19 N STE B
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16441-9739
Mailing Address - Country:US
Mailing Address - Phone:814-877-8790
Mailing Address - Fax:814-796-4238
Practice Address - Street 1:991 ROUTE 19 N STE B
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:PA
Practice Address - Zip Code:16441-9739
Practice Address - Country:US
Practice Address - Phone:814-877-8790
Practice Address - Fax:814-796-4238
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD051679L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA143214OtherUNISON
OH2235889OtherOH MEDICAL ASSISTANCE
PA207528OtherUPMC
PA3427509OtherAETNA
PA769128OtherBLUE SHIELD
NY02141922OtherNY MEDICAL ASSISTANCE
NY00025821402OtherUNIVERA
PAP00053926OtherRR MEDICARE
PA0014663120007Medicaid
PAP000873OtherGATEWAY
PA769128OtherBLUE SHIELD
PA769128E7CMedicare PIN