Provider Demographics
NPI:1982687158
Name:MOORE, THERESA A (NP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1226 E WATER ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1155
Mailing Address - Country:US
Mailing Address - Phone:315-478-4185
Mailing Address - Fax:315-478-0840
Practice Address - Street 1:739 IRVING AVE
Practice Address - Street 2:SUITE 600
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1651
Practice Address - Country:US
Practice Address - Phone:315-471-0190
Practice Address - Fax:315-471-0170
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY302160363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000923428001OtherHEALTHNOW PROVIDER NUMBER
NY000923428001OtherHEALTHNOW PROVIDER NUMBER
NYBB9882Medicare ID - Type Unspecified