Provider Demographics
NPI:1790853422
Name:MOORE, DOUGLAS BERNARD (PA-C)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:BERNARD
Last Name:MOORE
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:PO BOX 1535
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98401-1535
Mailing Address - Country:US
Mailing Address - Phone:253-761-4200
Mailing Address - Fax:253-383-3553
Practice Address - Street 1:1304 FAWCETT AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-1911
Practice Address - Country:US
Practice Address - Phone:253-761-4200
Practice Address - Fax:253-383-3553
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10005095363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0215666OtherLABOR AND INDUSTRIES-TRA
WA8862653OtherMEDICARE PIN-TRA KING
WA8943157OtherLABOR AND INDUSTRIES CRIME VICTIMS-TRA
WAP00428602OtherRR MEDICARE-TRA
WA8862652OtherMEDICARE PIN-TRA PIERCE
WA8862654OtherMEDICARE PIN-UNION AVENUE OPEN MRI
WA0249530OtherLABOR AND INDUSTRIES-MEDICAL IMAGING ON 1ST
WA8951854OtherLABOR AND INDUSTRIES CRIME VICTIMS-MEDICAL IMAGING ON 1ST
WA8862652OtherMEDICARE PIN-TRA PIERCE