Provider Demographics
NPI:1700053394
Name:MOORE, MATTHEW HENRY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:HENRY
Last Name:MOORE
Suffix:
Gender:M
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 1:111 S TREATY RD
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74354-5327
Mailing Address - Country:US
Mailing Address - Phone:918-540-1511
Mailing Address - Fax:918-542-7374
Practice Address - Street 1:111 S TREATY RD
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354
Practice Address - Country:US
Practice Address - Phone:918-540-1511
Practice Address - Fax:918-542-7374
Is Sole Proprietor?:No
Enumeration Date:2008-05-13
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1732363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200207110AMedicaid
OK100736700OMedicaid
OK900522214Medicare PIN
OK320049YKW9Medicare PIN
OKDA1415OtherRR MEDICARE GROUP