MEDICARE: JASON ANTHONY MOORE PA-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	PAT9110628	FL

General Provider Information

NPI Number	:	1902325681
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASON ANTHONY MOORE PA-C

Provider Business Mailing Address
First Line	:	13861 PLANTATION RD STE 104
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33912-4342
Country	:	US
Telephone Number	:	239-225-1306
Fax Number	:	239-768-1313

Provider Business Practice Location Address
First Line	:	13861 PLANTATION RD STE 104
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33912-4342
Country	:	US
Telephone Number	:	239-225-1306
Fax Number	:	239-768-1313

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

Provider Enumeration Date	:	09/14/2017
Last Update Date	:	07/21/2022

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