Provider Demographics
NPI:1295395333
Name:MOORE, MARIA (PA-C)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:MOORE
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:
Other - Last Name:GAYNIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:122 E OAK ST
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-1822
Mailing Address - Country:US
Mailing Address - Phone:678-209-3046
Mailing Address - Fax:678-209-3046
Practice Address - Street 1:160 MINE LAKE CT STE 200
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-6417
Practice Address - Country:US
Practice Address - Phone:520-390-1793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3876363AM0700X, 363AS0400X
NC0010-14553363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical