Provider Demographics
NPI:1659717163
Name:MOORE, PAUL
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:854 PARKCREST DR
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-5198
Mailing Address - Country:US
Mailing Address - Phone:828-773-2702
Mailing Address - Fax:
Practice Address - Street 1:108 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-5000
Practice Address - Country:US
Practice Address - Phone:828-262-3886
Practice Address - Fax:828-265-4816
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-13
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL002554133N00000X, 133NN1002X
949600133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education