MEDICARE: MR. DAVID WENDELL MOORE PA-C

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA347	KY

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	611369666	OTHER	KY	HUMANA PIN
3	000000299029	OTHER	KY	ANTHEM PIN
4	11368446	OTHER		CAQH PROVIDER ID
5	CS1801900158	OTHER		CARESOURCE ID
6	164291500	OTHER	KY	DEPARTMENT OF LABOR
7	84555KYIP	OTHER	KY	AETNA BETTER HEALTH OF KY PROVIDER ID NUMBER
8	1468559	OTHER	KY	WELLCARE OF KY PROVIDER ID NUMBER
9	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
10	7085548	OTHER		AETNA PIN

NPI Number	:	1427003524
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAVID WENDELL MOORE PA-C

Provider Business Mailing Address
First Line	:	PO BOX 21890
Second Line	:
City	:	BELFAST
State	:	ME
Zip	:	04915-4115
Country	:	US
Telephone Number	:	502-907-0356
Fax Number	:	502-919-9780

Provider Business Practice Location Address
First Line	:	101 PROSPEROUS PL STE 300
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40509-1836
Country	:	US
Telephone Number	:	859-275-5229
Fax Number	:	859-977-2683

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

Provider Enumeration Date	:	05/24/2006
Last Update Date	:	06/09/2022

101 PROSPEROUS PLACE , SUITE 300
LEXINGTON, KY
40509-1836

Practice Phone: 859-271-3114
Practice Fax: 859-271-0220