Provider Demographics
NPI:1821146044
Name:DOHERTY, MOIRA E (ARNP)
Entity Type:Individual
Prefix:
First Name:MOIRA
Middle Name:E
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3410 S SCHOOL AVE
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-5230
Mailing Address - Country:US
Mailing Address - Phone:941-951-1717
Mailing Address - Fax:
Practice Address - Street 1:3410 S SCHOOL AVE
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-5230
Practice Address - Country:US
Practice Address - Phone:941-960-3235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3253592363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL305882400Medicaid
FLY8169OtherBLUE CROSS OF FL
FLY8169OtherBLUE CROSS OF FL
FL305882400Medicaid