Provider Demographics
NPI:1740204189
Name:MOORE, PATRICIA (MD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 HANDLEY RD STE A
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:GA
Mailing Address - Zip Code:30290-2178
Mailing Address - Country:US
Mailing Address - Phone:770-997-5714
Mailing Address - Fax:770-997-2810
Practice Address - Street 1:190 HANDLEY RD
Practice Address - Street 2:
Practice Address - City:TYRONE
Practice Address - State:GA
Practice Address - Zip Code:30290-2178
Practice Address - Country:US
Practice Address - Phone:770-997-5714
Practice Address - Fax:770-997-2810
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA056875207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA7966709OtherAETNA
GA741370127FMedicaid
GA741370127FMedicaid
GA7966709OtherAETNA