Provider Demographics
NPI:1710462734
Name:MOORE, ANDREW MARC
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:MARC
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 1:2105 SHERBROOKE LN
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37211-7029
Mailing Address - Country:US
Mailing Address - Phone:865-776-8490
Mailing Address - Fax:
Practice Address - Street 1:3535 PENTAGON BLVD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-1705
Practice Address - Country:US
Practice Address - Phone:937-702-4024
Practice Address - Fax:937-702-4035
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3688363AM0700X
OH50.005821RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical