Provider Demographics
NPI:1821049206
Name:MOORE, QADARA FARIH (PA-C)
Entity Type:Individual
Prefix:
First Name:QADARA
Middle Name:FARIH
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 1:374 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06513-3733
Mailing Address - Country:US
Mailing Address - Phone:203-777-7411
Mailing Address - Fax:203-777-6508
Practice Address - Street 1:374 GRAND AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06513-3733
Practice Address - Country:US
Practice Address - Phone:203-777-7411
Practice Address - Fax:203-777-6508
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001633363AM0700X
NY012904363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6543809OtherNEW YORK STATE (CERTIFICATE NUMBER)
1066955OtherNCCPA CERTIFICATION
NY012904OtherNEW YORK STATE (LICENSE NUMBER)
CT11485065OtherCAQH
CT38064OtherCONNECTICUT CONNECTICUT CONTROLLED SUBSTANCE
CT38064OtherCONNECTICUT CONNECTICUT CONTROLLED SUBSTANCE
CT11485065OtherCAQH
CT970001903Medicare ID - Type Unspecified