Provider Demographics
NPI:1245437011
Name:MOORE, KEVIN ANDREW (MPT)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:ANDREW
Last Name:MOORE
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 STATE ST
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-1403
Mailing Address - Country:US
Mailing Address - Phone:315-393-2024
Mailing Address - Fax:315-393-2025
Practice Address - Street 1:203 STATE ST
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-1403
Practice Address - Country:US
Practice Address - Phone:315-393-2024
Practice Address - Fax:315-393-2025
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029435-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist