Provider Demographics
NPI:1609869197
Name:MOORE, DEBORAH D (PAC)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:D
Last Name:MOORE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 BELLEVUE RD
Mailing Address - Street 2:STE 21A
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2890
Mailing Address - Country:US
Mailing Address - Phone:478-328-0281
Mailing Address - Fax:478-328-0438
Practice Address - Street 1:1157 FORSYTH ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-7452
Practice Address - Country:US
Practice Address - Phone:478-745-8581
Practice Address - Fax:478-328-0438
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002158363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADC4061OtherRAILROAD MEDICARE
GA100000662Medicaid
GAP00168580OtherRAILROAD MEDICARE
GADC4061OtherRAILROAD MEDICARE
GAGRP6800Medicare PIN
GA97WCFZCMedicare PIN