MEDICARE: THOMAS E. MOOSE RPA-C

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	363AM0700X	Medical Physician Assistant	006431	NY

General Provider Information

NPI Number	:	1467415471
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS E. MOOSE RPA-C

Provider Business Mailing Address
First Line	:	12 CHELSEA WAY
Second Line	:
City	:	FAIRPORT
State	:	NY
Zip	:	14450-3215
Country	:	US
Telephone Number	:	585-425-3245
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 CANAL VIEW BLVD
Second Line	:	SUITE 102
City	:	ROCHESTER
State	:	NY
Zip	:	14623-2852
Country	:	US
Telephone Number	:	585-461-5330
Fax Number	:	585-461-9895

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

Provider Enumeration Date	:	04/10/2006
Last Update Date	:	07/08/2007

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