Provider Demographics
NPI:1639833346
Name:MOORE, AUSTIN RAY (PTA)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:RAY
Last Name:MOORE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 ALBANY ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-3402
Mailing Address - Country:US
Mailing Address - Phone:937-496-6200
Mailing Address - Fax:937-496-1990
Practice Address - Street 1:320 ALBANY ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3402
Practice Address - Country:US
Practice Address - Phone:937-496-6200
Practice Address - Fax:937-496-1990
Is Sole Proprietor?:No
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA-012906225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant