Provider Demographics
NPI:1861504326
Name:MOORE, MARK G (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:G
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 1:700 24TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:VA
Mailing Address - Zip Code:23801-1716
Mailing Address - Country:US
Mailing Address - Phone:804-734-9942
Mailing Address - Fax:877-874-1008
Practice Address - Street 1:700 24TH ST
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:VA
Practice Address - Zip Code:23801-1716
Practice Address - Country:US
Practice Address - Phone:804-734-9942
Practice Address - Fax:877-874-1008
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3260363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant