Provider Demographics
NPI:1518549849
Name:MOORE, GEOFFREY PAUL (PTA)
Entity Type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:PAUL
Last Name:MOORE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 CENTRE POINTE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-1179
Mailing Address - Country:US
Mailing Address - Phone:651-631-4242
Mailing Address - Fax:
Practice Address - Street 1:3050 CENTRE POINTE DR STE 200
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-1179
Practice Address - Country:US
Practice Address - Phone:651-631-4242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA704225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant