Provider Demographics
NPI:1710407150
Name:MOORE, ALISHA MARIE
Entity Type:Individual
Prefix:
First Name:ALISHA
Middle Name:MARIE
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1957 VIC GREEN RD
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35475-4964
Mailing Address - Country:US
Mailing Address - Phone:205-792-3433
Mailing Address - Fax:
Practice Address - Street 1:100 RICE MINE RD N STE B
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35406-2375
Practice Address - Country:US
Practice Address - Phone:205-349-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL630900428207R00000X
AL1-116590363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine