Provider Demographics
NPI:1134736341
Name:MOORE, SARA AMALIA (MAT, ATC)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:AMALIA
Last Name:MOORE
Suffix:
Gender:F
Credentials:MAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:443 S MAIN ST APT 1
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-3156
Mailing Address - Country:US
Mailing Address - Phone:925-519-3359
Mailing Address - Fax:
Practice Address - Street 1:300 PULTENEY ST
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-3304
Practice Address - Country:US
Practice Address - Phone:315-781-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-30
Last Update Date:2024-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000052450OtherBOARD OF CERTIFICATION