Provider Demographics
NPI:1659081297
Name:MOORE, HANNAH GRACE
Entity Type:Individual
Prefix:
First Name:HANNAH
Middle Name:GRACE
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HANNAH
Other - Middle Name:GRACE
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 METROPOLITAN PARK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-7112
Mailing Address - Country:US
Mailing Address - Phone:315-870-9369
Mailing Address - Fax:
Practice Address - Street 1:806 W BROADWAY
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-1571
Practice Address - Country:US
Practice Address - Phone:315-297-4700
Practice Address - Fax:315-218-5898
Is Sole Proprietor?:No
Enumeration Date:2022-12-05
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY350677363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily