Provider Demographics
NPI:1912307778
Name:MOORE, MIRANDA (PA-C)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:
Other - Last Name:FINCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1100 REID PARKWAY
Mailing Address - Street 2:MEDICAL STAFF SERVICE
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1157
Mailing Address - Country:US
Mailing Address - Phone:765-935-5331
Mailing Address - Fax:765-983-3219
Practice Address - Street 1:1050 REID PKWY STE 100
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1156
Practice Address - Country:US
Practice Address - Phone:765-935-8454
Practice Address - Fax:765-935-8453
Is Sole Proprietor?:No
Enumeration Date:2014-08-29
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IN1000372A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH373990Medicare PIN