Provider Demographics
NPI:1710926027
Name:MOORE, DEBORAH C (FNP)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:C
Last Name:MOORE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2700
Mailing Address - Country:US
Mailing Address - Phone:231-935-0600
Mailing Address - Fax:231-935-0613
Practice Address - Street 1:550 MUNSON AVE
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3580
Practice Address - Country:US
Practice Address - Phone:231-935-5800
Practice Address - Fax:231-935-9116
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704181867363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0B84507019 019Medicare ID - Type Unspecified
MIP23973Medicare UPIN