Provider Demographics
NPI:1760765317
Name:MOORE, CAROLYN ANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ANNE
Last Name:MOORE
Suffix:
Gender:F
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:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:3 AUDUBON PLAZA DR
Practice Address - Street 2:STE.560
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1300
Practice Address - Country:US
Practice Address - Phone:502-636-8004
Practice Address - Fax:502-636-8384
Is Sole Proprietor?:No
Enumeration Date:2011-09-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC080363AS0400X
KYPA1686363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK037382Medicare PIN