Provider Demographics
NPI:1588653794
Name:MOORE, REMIS MARK (PA-C)
Entity Type:Individual
Prefix:
First Name:REMIS
Middle Name:MARK
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:DEPT. #394
Mailing Address - Street 2:P.O. BOX 1000
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:941-300-4440
Mailing Address - Fax:941-404-1760
Practice Address - Street 1:601 MATLOCK CENTRE CIR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015-2535
Practice Address - Country:US
Practice Address - Phone:817-693-1000
Practice Address - Fax:904-293-4222
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
AZ3161363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9117098OtherFL DOH LICENSE
97BBDQJMedicare ID - Type Unspecified