Provider Demographics
NPI:1902190572
Name:MOORE, KEITH LOUIS (PA-C)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:LOUIS
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 1:1374 MEADOWS BLVD
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33327-1804
Mailing Address - Country:US
Mailing Address - Phone:954-288-7860
Mailing Address - Fax:
Practice Address - Street 1:4007 ESTATE DIAMOND RUBY
Practice Address - Street 2:
Practice Address - City:CHRISTIANSTED
Practice Address - State:VI
Practice Address - Zip Code:00820-4435
Practice Address - Country:US
Practice Address - Phone:340-778-6311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-01
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3389363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant