Provider Demographics
NPI:1649002692
Name:MOORE, ROSE AIMEE (PA-C)
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:AIMEE
Last Name:MOORE
Suffix:
Gender:
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 276950
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-6950
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 OLD SAN FRANCISCO RD
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94086-6385
Practice Address - Country:US
Practice Address - Phone:408-730-4262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-19
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA65069363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA65069OtherCALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS