Provider Demographics
NPI:1821312174
Name:MOORE, DANIEL J (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:J
Last Name:MOORE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:401 S BALLENGER HWY
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3638
Mailing Address - Country:US
Mailing Address - Phone:810-342-1000
Mailing Address - Fax:810-342-1590
Practice Address - Street 1:6465 MILLENNIUM
Practice Address - Street 2:SUITE 100
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-6880
Practice Address - Country:US
Practice Address - Phone:517-975-3720
Practice Address - Fax:517-975-3748
Is Sole Proprietor?:No
Enumeration Date:2010-03-16
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601004846363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant