Provider Demographics
NPI:1528041381
Name:MOORE, BRANDI N (PA)
Entity Type:Individual
Prefix:MS
First Name:BRANDI
Middle Name:N
Last Name:MOORE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:BRANDI
Other - Middle Name:N
Other - Last Name:CANNOY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1123 POWDER MILL RD
Mailing Address - Street 2:
Mailing Address - City:IVANHOE
Mailing Address - State:VA
Mailing Address - Zip Code:24350-3559
Mailing Address - Country:US
Mailing Address - Phone:276-699-0105
Mailing Address - Fax:
Practice Address - Street 1:245 FORT CHISWELL RD STE D
Practice Address - Street 2:
Practice Address - City:MAX MEADOWS
Practice Address - State:VA
Practice Address - Zip Code:24360-3987
Practice Address - Country:US
Practice Address - Phone:276-613-6991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-002204207Q00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10220815Medicaid
VA010220793Medicaid
VA010220807Medicaid
VA1068476OtherNCCPA CERTIFICATE NUMBER
VA010220807Medicaid
009457C87Medicare PIN
009459C63Medicare PIN
009458C86Medicare PIN