Provider Demographics
NPI:1942332812
Name:MOORE, DESIREE YOUNG (NP)
Entity Type:Individual
Prefix:MS
First Name:DESIREE
Middle Name:YOUNG
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3002 SAM HOUSTON DR
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-2682
Mailing Address - Country:US
Mailing Address - Phone:361-578-5730
Mailing Address - Fax:361-578-4511
Practice Address - Street 1:3002 SAM HOUSTON DR
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-2682
Practice Address - Country:US
Practice Address - Phone:361-578-5730
Practice Address - Fax:361-578-4511
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX522797363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXQ54873Medicare UPIN