Provider Demographics
NPI:1134978661
Name:MOORE, VICTORIA
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:MOORE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 GERDING DR
Mailing Address - Street 2:
Mailing Address - City:WINGATE
Mailing Address - State:NC
Mailing Address - Zip Code:28174-9601
Mailing Address - Country:US
Mailing Address - Phone:336-467-3337
Mailing Address - Fax:
Practice Address - Street 1:130 JAMES AVE
Practice Address - Street 2:
Practice Address - City:LOCUST
Practice Address - State:NC
Practice Address - Zip Code:28097-4506
Practice Address - Country:US
Practice Address - Phone:704-271-3777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-16
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X, 363AS0400X
NC0010-15251363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical