Provider Demographics
NPI:1356388433
Name:MOORE, BRYAN RUSSELL (PAA)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:RUSSELL
Last Name:MOORE
Suffix:
Gender:M
Credentials:PAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2540 WINDY HILL RD SE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-8605
Mailing Address - Country:US
Mailing Address - Phone:470-644-1274
Mailing Address - Fax:470-644-1119
Practice Address - Street 1:2540 WINDY HILL RD SE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8605
Practice Address - Country:US
Practice Address - Phone:470-644-1274
Practice Address - Fax:470-644-1119
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003912363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100002267CMedicaid
GAP00221726OtherRAILROAD MEDICARE
GA100002267BMedicaid
GA100002267BMedicaid