MEDICARE: MR. ANGELO DEWITT MOORE FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	138235	NC
2	363LF0000X	Family Nurse Practitioner	648115	TX

General Provider Information

NPI Number	:	1013099068
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ANGELO DEWITT MOORE FNP

Provider Business Mailing Address
First Line	:	21 MILLENNIUM LOOP
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10309-4337
Country	:	US
Telephone Number	:	718-630-4186
Fax Number	:

Provider Business Practice Location Address
First Line	:	1075 STEPHENSON AVE
Second Line	:	PATTERSON ARMY HEALTH CLINIC
City	:	FORT MONMOUTH
State	:	NJ
Zip	:	07703-5000
Country	:	US
Telephone Number	:	732-532-0182
Fax Number	:	732-532-0194

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2006
Last Update Date	:	09/11/2025

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