Provider Demographics
NPI:1770068942
Name:MOORE, OLIVER (DNP, APN, PMHNP-BC)
Entity type:Individual
Prefix:DR
First Name:OLIVER
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:DNP, APN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:532 MARLTON PIKE W # 407
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-2075
Mailing Address - Country:US
Mailing Address - Phone:323-853-8019
Mailing Address - Fax:
Practice Address - Street 1:550 BROAD ST STE 606
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-4537
Practice Address - Country:US
Practice Address - Phone:201-822-1161
Practice Address - Fax:877-485-8918
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-03
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00872800363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0813451Medicaid