Provider Demographics
NPI:1881701308
Name:MOORE, PAMELA M (NP)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:M
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:M
Other - Last Name:YODER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP
Mailing Address - Street 1:611 W. PARK ST.
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:217-383-4752
Practice Address - Street 1:611 W. PARK ST.
Practice Address - Street 2:CARDIOLOGY
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2500
Practice Address - Country:US
Practice Address - Phone:217-904-7000
Practice Address - Fax:217-904-7742
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN810052086S0129X
IL209-006880363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
103086OtherMC COCHISE
300051634OtherMARICOPA FOUND
448664OtherMERCY CARE
AZ103087OtherRR MC PIN
103087OtherMC PIMA
1Z1408OtherINTERGROUP HEALTHNET
300051634OtherHUMANA
448664OtherAHCCCS
AZAZ0819900OtherBCBS
AZ300051634OtherHEALTH PLAN AHP
300051634OtherCIGNA
AZ102542OtherRR MC GRP
AZ103086OtherRR MC PIN
500005593OtherTRAVELERS MC
300051634OtherAETNA
448664OtherINDIAN HEALTH
AZ448664Medicaid
S54711Medicare UPIN
AZ103086Medicare ID - Type Unspecified
AZ103087Medicare ID - Type Unspecified
AZ300051634OtherHEALTH PLAN AHP