Provider Demographics
NPI:1730139320
Name:MUZZALL-MOORE, MAURA LEE (PAC)
Entity Type:Individual
Prefix:MS
First Name:MAURA
Middle Name:LEE
Last Name:MUZZALL-MOORE
Suffix:
Gender:F
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:PO BOX 3188
Mailing Address - Street 2:
Mailing Address - City:OMAK
Mailing Address - State:WA
Mailing Address - Zip Code:98841-3188
Mailing Address - Country:US
Mailing Address - Phone:509-826-1600
Mailing Address - Fax:509-826-3633
Practice Address - Street 1:529 JASMINE ST
Practice Address - Street 2:
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841-9589
Practice Address - Country:US
Practice Address - Phone:529-826-1600
Practice Address - Fax:509-826-3633
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10000002975363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8931006OtherCRIME VICTIM COMPENSATION
WA5530MUOtherASURIS INSURANCE CO,
WA8371858Medicaid
WA0176649OtherWORKERS COMPENSATION
WA8371858Medicaid
R31452Medicare UPIN