Provider Demographics
NPI:1255018214
Name:MOORE, MIRANDA BROOKE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:BROOKE
Last Name:MOORE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7527
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-0727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5300 NIKE DR STE 100
Practice Address - Street 2:
Practice Address - City:HILLIARD
Practice Address - State:OH
Practice Address - Zip Code:43026-9813
Practice Address - Country:US
Practice Address - Phone:614-533-6080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-30
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.008160RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant