Provider Demographics
NPI:1619222528
Name:MOORE, SHAWN WILLIAM (FNP-C)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:WILLIAM
Last Name:MOORE
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-0658
Mailing Address - Country:US
Mailing Address - Phone:770-718-1122
Mailing Address - Fax:770-533-4786
Practice Address - Street 1:655 JESSE JEWELL PKWY SE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3854
Practice Address - Country:US
Practice Address - Phone:770-533-7288
Practice Address - Fax:770-534-9800
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN191172363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003125809Medicaid
GA003125809FMedicaid
GA003125809GMedicaid
GA003125809AMedicaid
GA003125809JMedicaid
GA003125809QMedicaid
GA01667286OtherAMERIGROUP
GA003125809BMedicaid
GA003125809LMedicaid
GA003125809IMedicaid
GA003125809KMedicaid