Provider Demographics
NPI:1619673316
Name:MOORE, KEVIN MATTHEW (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:MATTHEW
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 1:448 CASTROVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-5147
Mailing Address - Country:US
Mailing Address - Phone:210-434-1400
Mailing Address - Fax:210-431-7472
Practice Address - Street 1:448 CASTROVILLE RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-5147
Practice Address - Country:US
Practice Address - Phone:210-434-1400
Practice Address - Fax:210-431-7472
Is Sole Proprietor?:No
Enumeration Date:2023-02-03
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA16479363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant