Provider Demographics
NPI:1700859006
Name:MORO, RICHARD DOMINICK (PAC)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:DOMINICK
Last Name:MORO
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:558 NORWICH RD
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06374-1725
Mailing Address - Country:US
Mailing Address - Phone:608-564-4054
Mailing Address - Fax:608-564-0354
Practice Address - Street 1:558 NORWICH RD
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:CT
Practice Address - Zip Code:06374-1725
Practice Address - Country:US
Practice Address - Phone:608-564-4054
Practice Address - Fax:608-564-0354
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC104122363A00000X
NY004547-1363A00000X
CT001890363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
2V7860OtherHEALTHNET
2V7860OtherHEALTHNET