Provider Demographics
NPI:1598870750
Name:MOORE, CHARLOTTE T (PA)
Entity Type:Individual
Prefix:MRS
First Name:CHARLOTTE
Middle Name:T
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 1:185 ROSSDHU AVE
Mailing Address - Street 2:
Mailing Address - City:PAWLEYS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29585-5871
Mailing Address - Country:US
Mailing Address - Phone:843-237-8313
Mailing Address - Fax:
Practice Address - Street 1:116 BASKERVILL DR
Practice Address - Street 2:
Practice Address - City:PAWLEYS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29585-6013
Practice Address - Country:US
Practice Address - Phone:843-237-2672
Practice Address - Fax:843-237-0369
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA246363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCA246OtherPA LICENSE NUMBER