Provider Demographics
NPI:1295158103
Name:MOORE, KAITLIN ELIZABETH (PA)
Entity type:Individual
Prefix:MRS
First Name:KAITLIN
Middle Name:ELIZABETH
Last Name:MOORE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8230 WALNUT HILL LN STE 220
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4425
Mailing Address - Country:US
Mailing Address - Phone:214-345-8692
Mailing Address - Fax:
Practice Address - Street 1:8230 WALNUT HILL LN STE 220
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4425
Practice Address - Country:US
Practice Address - Phone:214-345-8692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-28
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08827363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX391943YKQLMedicare PIN