Provider Demographics
NPI:1033083753
Name:MOORE, TIA
Entity type:Individual
Prefix:
First Name:TIA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10535 TOLLGATE RD SW
Mailing Address - Street 2:
Mailing Address - City:ETNA
Mailing Address - State:OH
Mailing Address - Zip Code:43062-8324
Mailing Address - Country:US
Mailing Address - Phone:614-636-9987
Mailing Address - Fax:
Practice Address - Street 1:6100 E MAIN ST STE 110
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-3399
Practice Address - Country:US
Practice Address - Phone:614-861-1120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-04
Last Update Date:2025-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0040480363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner