Provider Demographics
NPI:1710538566
Name:MOORES, BRENDAN TYLER (PA-C)
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:TYLER
Last Name:MOORES
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 1:1717 N INTERSTATE 35 STE 200
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-2901
Mailing Address - Country:US
Mailing Address - Phone:512-964-6992
Mailing Address - Fax:
Practice Address - Street 1:1717 N INTERSTATE 35 STE 200
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-2901
Practice Address - Country:US
Practice Address - Phone:512-964-6992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA13040363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant