Provider Demographics
NPI:1811148133
Name:MOYER, LAURIE E (PA-C)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:E
Last Name:MOYER
Suffix:
Gender:F
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 1:1802 BRAEBURN DR
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-7357
Mailing Address - Country:US
Mailing Address - Phone:540-772-3530
Mailing Address - Fax:
Practice Address - Street 1:1802 BRAEBURN DR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7357
Practice Address - Country:US
Practice Address - Phone:540-772-3530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-06
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002918363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1811148133Medicaid
VA1811148133Medicaid
VAVV0283AMedicare PIN