Provider Demographics
NPI:1962489567
Name:MOORE, MARK (CFNP)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:CFNP
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Other - Credentials:
Mailing Address - Street 1:1600 22ND AVE
Mailing Address - Street 2:MEDICAL TOWERS III
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-3223
Mailing Address - Country:US
Mailing Address - Phone:601-483-5322
Mailing Address - Fax:601-581-2289
Practice Address - Street 1:1600 22ND AVE
Practice Address - Street 2:MEDICAL TOWERS III
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-3223
Practice Address - Country:US
Practice Address - Phone:601-483-5322
Practice Address - Fax:601-581-2289
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MSR669059363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02904207Medicaid
MS500001600Medicare ID - Type Unspecified
MS02904207Medicaid