Provider Demographics
NPI:1861688962
Name:MOORE, DANYA M (PAC)
Entity Type:Individual
Prefix:MRS
First Name:DANYA
Middle Name:M
Last Name:MOORE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:922 TRIPLETT STREET
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-3222
Mailing Address - Country:US
Mailing Address - Phone:270-685-5077
Mailing Address - Fax:
Practice Address - Street 1:922 TRIPLETT ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-3118
Practice Address - Country:US
Practice Address - Phone:270-685-5077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-21
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY363A00000X
KYPA1063363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000536383OtherANTHEM
KY000000668071OtherCOOP HEALTH ANTHEM #
KY0649922Medicare PIN
IN202280ZMedicare PIN
000000536383OtherANTHEM