MEDICARE: SIDNEY CELINE MOORE PHYSICIAN ASSISTANT

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	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1194699199
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SIDNEY CELINE MOORE PHYSICIAN ASSISTANT

Provider Business Mailing Address
First Line	:	4850 MILLENIA BLVD
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32839-6012
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1728 DUNLAWTON AVE STE 5
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32127-2923
Country	:	US
Telephone Number	:	386-304-3404
Fax Number	:

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

Provider Enumeration Date	:	10/02/2025
Last Update Date	:	03/28/2026

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