Provider Demographics
NPI:1588623367
Name:MOORE, JENNIFER MARIE (PA)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:MARIE
Last Name:MOORE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 HOCUTT FARM DR
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27527-3751
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1110 KILDAIRE FARM RD
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-4523
Practice Address - Country:US
Practice Address - Phone:919-481-0277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010268-1363A00000X
NC001002915363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02670611Medicaid
NYP00204701OtherRR MEDICARE PIN
NYCC8362OtherRR MEDICARE GROUP
NY02670611Medicaid
NYCC8362OtherRR MEDICARE GROUP