Provider Demographics
NPI:1659342772
Name:MOORE, TANYA FERGUSON (PA-C)
Entity Type:Individual
Prefix:MS
First Name:TANYA
Middle Name:FERGUSON
Last Name:MOORE
Suffix:
Gender:F
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 1:607 IDOL ST
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-7804
Mailing Address - Country:US
Mailing Address - Phone:336-802-2400
Mailing Address - Fax:336-802-2001
Practice Address - Street 1:905 PHILLIPS AVE
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-7075
Practice Address - Country:US
Practice Address - Phone:336-802-2145
Practice Address - Fax:336-802-2146
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAC00001967363AM0700X
NC100863363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2770974AMedicare PIN