Provider Demographics
NPI:1912367640
Name:MOORE, VIRGINIA (PA-C)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:MOORE
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 1:7810 RIDGELAND DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2269
Mailing Address - Country:US
Mailing Address - Phone:786-399-7131
Mailing Address - Fax:
Practice Address - Street 1:15791 BEAR VALLEY RD
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-1746
Practice Address - Country:US
Practice Address - Phone:760-949-1231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-23
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant