Provider Demographics
NPI:1679029458
Name:MOORE, ALYSSIA (PA)
Entity Type:Individual
Prefix:
First Name:ALYSSIA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26657 WOODWARD AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48070-1304
Mailing Address - Country:US
Mailing Address - Phone:248-398-8400
Mailing Address - Fax:
Practice Address - Street 1:26657 WOODWARD AVE STE 200
Practice Address - Street 2:
Practice Address - City:HUNTINGTON WOODS
Practice Address - State:MI
Practice Address - Zip Code:48070-1304
Practice Address - Country:US
Practice Address - Phone:248-957-7999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007869363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical