Provider Demographics
NPI:1568973576
Name:MOORE, RYAN PATRICK (PA-C)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:PATRICK
Last Name:MOORE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34612 6TH AVE S STE 300
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-8723
Mailing Address - Country:US
Mailing Address - Phone:253-838-8552
Mailing Address - Fax:
Practice Address - Street 1:34612 6TH AVE S STE 300
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-8723
Practice Address - Country:US
Practice Address - Phone:253-838-8552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA.0777859363AS0400X
WAOA60803041363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2096256Medicaid