Provider Demographics
NPI:1902348915
Name:MOORE, MICHAEL R (DPT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:MOORE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:510 8TH AVE NE STE 320
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98029-5436
Mailing Address - Country:US
Mailing Address - Phone:425-313-3055
Mailing Address - Fax:425-313-3051
Practice Address - Street 1:1200 112TH AVE NE STE C260
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3746
Practice Address - Country:US
Practice Address - Phone:425-313-3055
Practice Address - Fax:425-313-3051
Is Sole Proprietor?:No
Enumeration Date:2016-11-08
Last Update Date:2025-01-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WA60662480225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2069871Medicaid